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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThis article discusses studies that have provided insights into the role of intravascular ultrasound guidance in optimal coronary stenting, predictors of thrombosis after successful implantation of drug-eluting stents, an the incidence and mechanisms of stent thrombosis, among other things.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices Thrombotic Disorders\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EBrian \u00d3 Murch\u00fa, MD, Temple University, Philadelphia, Pennsylvania, USA, discussed studies that have provided insights into the role of intravascular ultrasound (IVUS) guidance in optimal coronary stenting. Among the first studies to identify a role for IVUS in stenting was the CRUISE substudy of the STARS trial, which suggested that IVUS guidance of stent implantation may result in more effective stent expansion compared with angiographic guidance alone. After 9 months, centers that used IVUS guidance achieved significantly larger minimal stent dimensions than centers that used angiographic guidance alone (ie, minimal lumen diameter, 2.9\u00b10.4 vs 2.7\u00b10.5 mm, p\u0026lt;0.001 by quantitative coronary angiography and minimal stent area; 7.78\u00b11.72 vs 7.06\u00b12.13 mm\u003Csup\u003E2\u003C\/sup\u003E, p\u0026lt;0.001 by quantitative coronary ultrasound. [Fitzgerald PJ et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2000]. In 2008, further evidence of a possible benefit for IVUS was provided via the results single center registry that compared the rate of definite stent thrombosis at 12 months between 884 consecutive patients who were undergoing IVUS-guided intracoronary drug-eluting stent (DES) implantation and a propensity-score matched population that was undergoing DES implantation with angiographic guidance alone. The results of this observational study indicated that IVUS guidance during DES implantation has the potential to influence treatment strategy and reduce both DES thrombosis and the need for repeat revascularization [Roy P et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2008]. Researchers are anxiously awaiting the results of the Angiography Versus IVUS Optimisation trial (AVIO; \u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT00936169\u0026amp;atom=%2Fspmdc%2F10%2F8%2F28.atom\u0022\u003ENCT00936169\u003C\/a\u003E), a randomized, open-label trial that aims to determine whether IVUS-guided DES implantation in complex lesions is superior to angiographically-guided implantation in improving postprocedural minimum lumen diameter.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EStent thrombosis remains an important complication for both DES and bare metal stents (BMS). Alaide Chieffo, MD, San Raffaele Scientific Institute, Milan, Italy, discussed some predictors of thrombosis after successful implantation of DES (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E), including dual antiplatelet therapy (DAPT)\u2014an important component of poststent therapy whose premature discontinuation has been shown to be a significant predictor of thrombosis [Airoldi F et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2007; Park SJ et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2010]. Other factors that influence the efficacy of DAPT include genotype or phenotype issues that influence a patient\u0027s ability to metabolize clopidogrel [Gurbel PA et al. \u003Cem\u003EExpert Opin Drug Metab Toxicol\u003C\/em\u003E 2009; Holmes DR et al. \u003Cem\u003EJ Am Col Cardiol\u003C\/em\u003E 2010], as well as the overall efficacy of newer antiplatelet dugs, such as prasugrel [Wiviott SD et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2007] and ticagrelor [Wallentin L et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2009].\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/8\/28\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Predictors of Thrombosis After Successful Implantation of DES.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1733412005\u0022 data-figure-caption=\u0022Predictors of Thrombosis After Successful Implantation of DES.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/8\/28\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/8\/28\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/8\/28\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11470\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-4\u0022 class=\u0022first-child\u0022\u003EPredictors of Thrombosis After Successful Implantation of DES.\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EReproduced with permission from A. Chieffo, MD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-5\u0022\u003EAlthough the incidence of coronary artery aneurysms (CANs) after DES implantation is rare (0.2% to 2.3% of patients) [Aoki J et al. \u003Cem\u003EJ Am Col Cardiovasc Interv\u003C\/em\u003E 2008], they are frequently associated with adverse clinical events. Fernando Alfonso, MD, PhD, San Carlos University Hospital, Madrid, Spain, discussed the results of a study that was conducted to assess clinical, angiographic, and IVUS findings in patients who were developing a CAN after DES implantation [Alfonso F et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2009]. The study comprised 1197 consecutive patients with late angiographic evaluation after DES implantation. CANs developed in 15 patients (1.25%; 95% CI, 0.58 to 1.93) and were more frequent when DES were implanted during acute myocardial infarction, in occluded vessels, long lesions, or residual dissections. Most patients with a CAN had an adverse prognosis (including DES thrombosis and death) that was almost always related to discontinuation of DAPT. After a mean follow-up of 399\u00b1347 days, the 1-year event-free survival was 49\u00b114% and was related to CAN size on IVUS. While coronary angiography was able to provide an accurate diagnosis of the CAN, IVUS provided further anatomical insights, including the extent of DES malapposition, which may have major prognostic implications (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E).\u003C\/p\u003E\u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/11476\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/11476\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11476\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-6\u0022 class=\u0022first-child\u0022\u003EIVUS Data of Coronary Aneursym According to Presence of DES Thrombosis.\u003C\/p\u003E\n         \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-7\u0022\u003EWhile discussing the incidence and mechanisms of stent thrombosis (ST), Stefan James, MD, Uppsala Clinical Research Center, Uppsala, Sweden, noted that it is an uncommon event, occurring in 0.5% to 1% of all patients during the first 6 months after stent implantation and then at a rate of \u223c0.5% per year for DES patients thereafter. The strongest predictor of ST is the presence of a STEMI as the original indication for stenting (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E) [Lagerqvist B et al. \u003Cem\u003ECirc Cardiovasc Int\u003C\/em\u003E 2009]. The use of stents in off-label indications and increased platelet aggregation are known to increase the risk of ST, while more efficient platelet aggregation reduces the risk [Angiolillo DJ et al. \u003Cem\u003EAm J Cardiovasc Drugs\u003C\/em\u003E 2007]. The use of DES is an independent predictor of ST only after the initial 6 months. There is also strong evidence that carriers of a reduced-function CYP2C19 allele who are treated with clopidogrel have significantly lower levels of the active metabolite of clopidogrel, diminished platelet inhibition, and a higher rate of major adverse cardiovascular events (MACEs), including stent thrombosis, than noncarriers [Mega JL et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2009].\u003C\/p\u003E\u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/8\/28\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Independent Predictors of Stent Thrombosis in Sweden.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1733412005\u0022 data-figure-caption=\u0022Independent Predictors of Stent Thrombosis in Sweden.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/8\/28\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/8\/28\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/10\/8\/28\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11472\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n            \u003Cp id=\u0022p-8\u0022 class=\u0022first-child\u0022\u003EIndependent Predictors of Stent Thrombosis in Sweden.\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReproduced with permission from S. James, MD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-9\u0022\u003EIndividuals who receive clopidogrel exhibit wide variability in platelet responses [Serebruany VL et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2005; Hochholzer W et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2005; Trenk D et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2008]; however, residual platelet function is a strong independent predictor of ST. Two large clinical studies are assessing the benefit of tailored antiplatelet therapy in elective PCI.\u003C\/p\u003E\u003Cp id=\u0022p-10\u0022\u003ETwo ongoing prospective, randomized, multicenter, double-blind, placebo-controlled trials are exploring novel strategies to reduce ischemic complications poststenting. The Gauging Responsiveness With A VerifyNow Assay-Impact On Thrombosis And Safety study (GRAVITAS; \u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT00645918\u0026amp;atom=%2Fspmdc%2F10%2F8%2F28.atom\u0022\u003ENCT00645918\u003C\/a\u003E) is designed to assess whether tailored antiplatelet therapy for poor responders, identified based on the results of the VerifyNow P2Y\u003Csub\u003E12\u003C\/sub\u003E Test, reduces MACEs (eg, heart attack, stent thrombosis) following percutaneous coronary intervention (PCI). The study population comprises \u223c2800 patients with stable angina\/ischemia or non-ST-elevation acute coronary syndrome who are undergoing PCI with DES. Patients with high residual platelet reactivity who are on clopidogrel therapy 12 to 24 hours post-PCI will be randomized to standard maintenance clopidogrel therapy (75 mg daily) or high-dose clopidogrel therapy (additional loading dose followed by 150 mg daily) for 6 months. A random sample of patients without high residual reactivity will be followed and treated with standard clopidogrel therapy for 6 months. The primary endpoint is the time to first occurrence of cardiovascular (CV) death, nonfatal myocardial infarction, or definite\/probable stent thrombosis. The study design and rationale have been previously published [Price MJ et al. \u003Cem\u003EAm Heart J\u003C\/em\u003E 2009]. Results will be reported at the American Heart Association meeting in November 2010.\u003C\/p\u003E\u003Cp id=\u0022p-11\u0022\u003ETesting Platelet Reactivity In Patients Undergoing Elective Stent Placement on Clopidogrel to Guide Alternative Therapy With Prasugrel (TRIGGER-PC; \u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT00910299\u0026amp;atom=%2Fspmdc%2F10%2F8%2F28.atom\u0022\u003ENCT00910299\u003C\/a\u003E) trial is designed to determine the efficacy of prasugrel versus clopidogrel for the reduction of adverse CV outcomes in patients with high platelet reactivity who are on clopidogrel after successful implantation of DES. The primary study outcome is time to first occurrence of heart attack or CV death. The study plans to enroll 2150 men or women with coronary artery disease and successful PCI with at least one DES. Subjects will be randomly assigned to receive a one-time 60-mg oral loading dose and a 10-mg once-daily oral maintenance dose of prasugrel for up to 6 months or clopidogrel 75 mg oral daily for up to 6 months. This study is enrolling and is not expected to complete until July 2012.\u003C\/p\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2010 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/10\/8\/28.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzmpa2\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzmpa2\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzmpa2\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}