Author + information
- David R. Holmes Jr., MD⁎ ()
- ↵⁎Cardiovascular Diseases and Internal Medicine, Mayo Clinic, 200 First Street, SW, MB 4-523, Rochester, Minnesota 55905
We appreciate the comments of Dr. Salinas and colleagues regarding our paper (1). The safety of new-generation stents is improving. This may be the result of several factors, one of which may be the use of “biodegradable” polymers; other factors may also be as important, including improved antiplatelet therapy, longer duration of antiplatelet therapy, and improved initial stent placement using high-pressure balloons or guidance with intravascular ultrasound and/or optical computed tomography. Of interest, in the authors' meta-analysis, there were 43 patients in the biodegradable group and 41 in the permanent polymer group. The numbers are therefore small, although any event is often catastrophic for the individual patient. Given the low incidence of the phenomenon and the changing technology, larger series and longer follow-up will be needed, although challenging. At the present time, a randomized trial with stent thrombosis as the primary end point is unavailable for study.
We also appreciate the comments of Prof. Kounis regarding Kounis syndrome. There are multiple issues involved in stent thrombosis. Some issues relate to the underlying coronary artery disease, some to the specific stent design, including bare-metal versus drug-eluting stents, and for drug-eluting stents in particular the specific polymer and drug or drugs used. In addition, there are issues of compliance with and response to dual-antiplatelet therapy. Findings consistent with hypersensitivity have been seen in some autopsy series, as mentioned by Prof. Kounis, and may play a role. Continuing ongoing experience with polymer-free designs as well as different drugs may help resolve some of the issues. Fortunately, the incidence of this often catastrophic complication is very low; this very fact makes reaching definitive evidence-based conclusions about preventive strategies challenging.
- American College of Cardiology Foundation