What complications are possible around 20 days post-myocardial infarction (MI) treated with a drug-eluting stent (DES)?

From the Guidelines

Complications around twenty days post-myocardial infarction treated with a drug-eluting stent (DES) primarily include stent thrombosis, in-stent restenosis, and bleeding complications from dual antiplatelet therapy (DAPT), emphasizing the need for strict adherence to DAPT and monitoring for signs of these complications.

Possible Complications

• Stent thrombosis: A serious concern that can cause sudden cardiac death or recurrent MI, necessitating adherence to DAPT as recommended by the European Society of Cardiology (ESC) in their 2017 focused update on dual antiplatelet therapy in coronary artery disease 1.
• In-stent restenosis: Less common with DES than with bare metal stents but still a possibility due to neointimal hyperplasia.
• Bleeding complications: A risk associated with DAPT, which can be mitigated by using low-dose aspirin and a low dose of P2Y12 inhibitor, as well as the routine use of proton pump inhibitors (PPI) as suggested by the ESC guidelines 1.
• Post-MI heart failure: Symptoms can include dyspnea and fatigue.
• Arrhythmias: Atrial fibrillation is a particular concern.
• Pericarditis (Dressler's syndrome): Inflammation of the pericardium that can occur weeks after MI.
• Mechanical complications: Though rare, include ventricular septal rupture or papillary muscle dysfunction.

Management and Prevention

The ESC guidelines recommend an individualized approach to DAPT duration based on ischemic versus bleeding risk assessment 1. For patients with a high ischemic risk and low bleeding risk, prolonged DAPT may be considered. However, the risk of bleeding should always be carefully weighed against the benefits of DAPT. The choice of P2Y12 inhibitor (e.g., clopidogrel, ticagrelor, or prasugrel) should be based on the patient's specific clinical scenario, including the presence of acute coronary syndrome (ACS) and any contraindications to specific drugs 1.

Monitoring and Patient Education

Patients should be educated on the signs and symptoms of these complications and instructed to seek immediate medical attention if they experience chest pain, shortness of breath, palpitations, or signs of bleeding. Regular follow-up appointments are crucial for monitoring the patient's condition and adjusting the treatment plan as necessary to minimize the risk of complications.

From the FDA Drug Label

The risk of bleeding is increased in patients receiving prasugrel who undergo CABG. If possible, prasugrel should be discontinued at least 7 days prior to CABG. For patients receiving a thienopyridine within 3 days prior to CABG, the frequencies of TIMI Major or Minor bleeding were 26.7% (12 of 45 patients) in the prasugrel group, compared with 5. 0% (3 of 60 patients) in the clopidogrel group. Premature discontinuation of any antiplatelet medication, including thienopyridines, conveys an increased risk of stent thrombosis, myocardial infarction, and death.

Possible complications around the twenty-day post-myocardial infarction treated with a DES stent include:

• Bleeding: increased risk of bleeding, especially if the patient undergoes CABG
• Stent thrombosis: increased risk if antiplatelet medication is discontinued prematurely
• Myocardial infarction: increased risk if antiplatelet medication is discontinued prematurely
• Death: increased risk if antiplatelet medication is discontinued prematurely 2

From the Research

Complications Around the Twenty Day Post Myocardial Infarction Treated with a DES Stent

• Possible complications around the twenty day post myocardial infarction treated with a drug-eluting stent (DES) include:
  • Stent thrombosis: a blood clot forming inside the stent, which can block blood flow to the heart 3, 4, 5, 6, 7
  • Myocardial infarction: damage to the heart muscle due to a blockage of blood flow 3, 4, 5, 6, 7
  • Major bleeding: bleeding that requires medical attention, such as gastrointestinal bleeding or bleeding in the brain 3, 4, 5, 6, 7
  • Cardiovascular and cerebrovascular adverse events: events such as stroke, heart attack, or death from cardiovascular causes 4, 5, 6, 7

Factors Influencing Complications

• The duration of dual antiplatelet therapy (DAPT) after DES stent placement can influence the risk of complications:
  • Short-term DAPT (≤ 3 months) may reduce the risk of major bleeding compared to longer-term DAPT 6, 7
  • Extended-term DAPT (> 12 months) may reduce the risk of myocardial infarction and stent thrombosis, but increase the risk of major bleeding 3, 4, 5
• The type of antiplatelet therapy used after DAPT can also influence the risk of complications:
  • Aspirin monotherapy after short-term DAPT may reduce the risk of bleeding compared to continued DAPT 4, 6
  • P2Y12 inhibitor monotherapy after short-term DAPT may reduce the risk of bleeding and stent thrombosis compared to continued DAPT 4, 6