When Can I Stop Taking
Plavix? (Updated)
A New Imaging Modality May Help Patients and Physicians Determine
Optimal Duration of Antiplatelet Therapy in the Not-Too-Distant Future
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June 3, 2008 -- The question
on the minds of a great many patients who
have had
a drug-eluting
stent implanted is: "When can I stop taking Plavix? When will
my drug-eluting stent be completely healed?" From
John in the
United Kingdom
to H. Percell in Oregon to Patrick M. in Florida, the Patient
Forums on Angioplasty.Org are filled with hundreds of postings
asking this question.
OCT image
just proximal to a stent in a Right Coronary Artery, courtesy
of the 1st in Man Volcano OCT performed at ThoraxCenter
in Rotterdam by Prof. Patrick Serruys
and Dr. Evelyn Regar |
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It's THE question
of the day, and no one is really sure of the answer. However,
according to a study published in the current American College
of Cardiology journal, JACC Interventions, a new imaging technology,
called Optical Coherence Tomography or
OCT, may help
with this issue in the not-too-distant future.
The problem is relatively straight-forward. As long as a
metal stent remains uncovered, the risk of blood clotting on
the strut surfaces inside the artery is higher.
Antiplatelet therapy keeps the blood slippery and minimizes
this risk while
the body's endothelial cells gather and cover the metal struts.
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But, until the development of OCT, there has been
no direct way to see if struts have been covered, except through
pathology specimens (it was in fact pathologist Renu Virmani who
was one of the early voices of concern regarding the delayed healing
around stents that she had seen in specimens from patients). And
having a method to visualize whether the stent has "healed" may
have significant implications for patients.
When
bare
metal
stents
first
arrived
on
the
scene over ten years ago,
the FDA required that
patients
be given
dual
antiplatelet
therapy
(aspirin plus clopidogrel,
a.k.a. Plavix or ticlopidine, a.k.a. Ticlid) for 4-6 weeks. Studies
showed that metal stents became covered by a protective layer of
endothelial cells in this time period, reducing the risk of blood
clotting. But in 20% of patients, tissue growth became so excessive
that it blocked the blood flow through the stent, causing the
very condition the stent was supposed to prevent. This phenomenon
was called " in-stent
restenosis".
Enter the drug-eluting stent, designed to
slow down the proliferation of
endothelial
cells and prevent them from aggregating too thickly. Because
of the anti-proliferative properties of these medicated stents,
the FDA more than tripled the length of antiplatelet therapy, allowing
3-6 months for the stent struts to become covered.
However, in
the fall of
2006, three years after U.S. approval, reports
surfaced of
increased late stent thrombosis (blood clotting inside the
stent after six months) with drug-eluting stents. Although
the percentage of patients affected was very low, less than 1%,
stent thrombosis can cause heart
attack or death
more
than a third
of the
time. Concerned about the public health implications, the FDA called
a special two-day hearing and one result was that
the
major heart organizations changed their guidelines to a one-year
minimum of dual antiplatelet therapy, assuming the patient does
not
experience bleeding complications or other adverse reactions. These
guidelines were written as a "best estimate", because there
have not been studies which conclude definitely the optimum duration
of antiplatelet therapy.
But there are several Catch-22s
that many patients face. What if a patient
does have
adverse reactions
to Plavix,
either
allergic rashes or bleeding complications? What if a patient
needs surgery, such as a knee-replacement, and Plavix has to be
stopped? What if a patient can't afford the $4/day cost of Plavix?
What
studies
have shown is that early cessation of antiplatelet therapy in drug-eluting
stent patients results in an increase in heart attack and death.
So
why is being able to see a stent important?
Dr.
Marc D.
Feldman, Director of the Cardiac
Catheterization Laboratories at University of Texas Health
Science Center, San Antonio, and a co-developer of OCT
technology, explained to Angioplasty.Org:
"How long do you continue Plavix for? The FDA just recommended
extending it to longer, 12 months. But for many of us,
that's not even long enough. We still see patients 2-3
years out
who are having acute stent thrombosis. You never saw
that with bare metal stents. The instance is only 1 in
200, right?
It's not very common, but does that mean every patient
with a drug-eluting stent gets put on Plavix forever? Or
can OCT
one day say 'Aha, that patient has thick endothelial
coverage on that drug-eluting stent. Therefore the risk
of acute stent
thrombosis is very low. Stop the Plavix!'"
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Marc
D. Feldman, MD |
Like intravascular ultrasound (IVUS),
OCT is a catheter-based system which is performed in a cath
lab. Although IVUS can image to a greater depth into the artery wall,
OCT provides a higher resolution of
the inner artery
surfaces (10 microns) and can easily show if stents have been covered.
The ability to image the surface at high resolution also allows OCT
to see very thin fibrous "caps" which
are known to cover lipid-rich cores in the artery, so-called
"vulnerable
plaques". These plaques tend to be about 30 microns thick, so
are easily identifiable using OCT. Identifying such areas may provide
early detection of problems and help direct treatment for the prevention
of heart attacks, especially in a system that may combine both OCT
and IVUS technologies to give a more complete picture of the coronary
artery.
A study comparing IVUS and OCT in animal models
has been published in the current issue of JACC Interventions,
the new American College of Cardiology journal, devoted to interventional
cardiology, and it concludes that
OCT has
the ability
to visualize coverage of the stent. Furthermore, the importance of
this imaging technology in determining the optimum duration of antiplatelet
therapy is highlighted in an accompanying editorial, co-authored
by Dr. Carlo Di Mario of Royal Brompton in
London:
"OCT has the potential to offer surrogate end
points to test the ability of new DES to promote consistent tissue
coverage
of all struts. Studies of new DES should include OCT substudies
of adequate size and with serial examinations at well-selected
time
intervals after implantation. Such studies could identify the
most promising DES and provide evidence to guide duration of
antiplatelet
treatment after different DES types."
Optical Coherence Tomography is still investigational,
but this new field is moving quickly. Less than a month after the JACC
Interventions animal study was published,
the First in Man Volcano OCT study commenced in Rotterdam. Results
from
these and other clinical work will be adding to the knowledge base
and
Volcano Corporation is hoping to have U.S. approval of their OCT
technology sometime in the second half of 2009.
For more information on OCT and other intravascular
imaging and measurement technologies, visit the Intravascular
Ultrasound Center on Angioplasty.Org.
Reported by Burt Cohen, June 3, 2008
(updated from May 29)
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