Author + information
- Stefanie Jellinghaus, MD∗ (, )
- Christian Pflücke, MD,
- Heda Kvakan, MD,
- Johannes Mierke, MD and
- Karim Ibrahim, MD
- ↵∗University Hospital Dresden, Department of Internal Medicine and Cardiology, Fetscherstrasse 76, Dresden 01307, Germany
We congratulate Shah et al. (1) for their excellent analysis of a very important question concerning stent thrombosis and hypothermia. However, from our point of view, there are some concerns that should be considered in detail.
First, the investigators did not define the different antiplatelet therapy strategies in detail, as prasugrel has been available since 2009. At present, the influence of hypothermia on the effectiveness of the newer adenosine diphosphate inhibitors such as prasugrel and ticagrelor is not sufficiently understood. The newer adenosine diphosphate inhibitors seem to be more effective, as the effectiveness of clopidogrel is reduced in therapeutic hypothermia (2,3).
Furthermore, it was shown that individually guided clopidogrel therapy significantly reduced adverse thrombotic events in patients undergoing coronary stent implantation (4). Therefore, it would have been of great interest to know whether the patients in the present study received tailored antiplatelet therapy with different loading doses.
Second, the investigators did not provide information about the kinds of drug-eluting stents implanted. As shown in the DAPT (Dual Antiplatelet Therapy) trial, there is increased risk for stent thrombosis with the use of paclitaxel-eluting stents compared with, for example, everolimus-eluting stents. This risk is further reduced with the use of prasugrel, as indicated in more intense platelet inhibition.
Taken together, a third issue must be discussed critically in this context. With an incidence of stent thrombosis of about 4% in the present study, related to a high proportion of patients with cardiogenic shock, the question is raised whether to treat coronary lesions simultaneously or only culprit lesion. Given that the incidence of complications is higher because of cardiogenic shock and hypothermia, a staged procedure that treats only culprit lesions seems to be the most feasible therapy. The solution may partially be found in ongoing trials such as the CULPRIT-SHOCK (Culprit Lesion Only PCI Versus Multivessel PCI in Cardiogenic Shock) trial (5).
The relatively high incidence of stent thrombosis in the present study again demonstrates that hypothermia treatment itself defines a high-risk patient, who needs more individualized antiplatelet therapy and a differentiated revascularization strategy.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation
- Shah N.,
- Chaudhary R.,
- Mehta K.,
- et al.
- Thiele H.,
- Desch S.,
- Piek J.J.,
- et al.