Ticlopidine Monotherapy for Coronary Stents
ABSTRACT & COMMENTARY
Synopsis: Ticlopidine monotherapy after elective stent placement in an unselected population is safe, effective, and comparable to other antiplatelet regimens.
Source: Elsner M, et al. Am J Cardiol 1998;81:147-151.
Prevention of acute thrombosis post coronary artery stenting has focused on antiplatelet therapy with aspirin and ticlopidine. Elsner and associates tested the hypothesis that ticlopidine monotherapy was safe and effective in a prospective trial of elective coronary stenting in 263 consecutive, unselected patients. A variety of available stents were used, without intravascular ultrasound guidance. Most of the patients (86%) had one or two vessel disease, and a total of 322 stents were deployed. All patients received ticlopidine (250 mg) twice a day for up to six months. There was no control group. In-hospital events included: two deaths (0.8%); five acute myocardial infarctions (1.9%); two target vessel occlusions; and two repeat angioplasties. At six months, follow-up further events included: two deaths; four acute myocardial infarctions (1.5%); four target vessel occlusions; 52 repeat angioplasties (20%); two bypass surgeries; and four cerebrovascular events. The main adverse effect with ticlopidine was gastrointestinal upset (7%). No neutopenia was observed during the mean follow-up of 4.4 months. Elsner et al conclude that ticlopidine monotherapy after elective stent placement in an unselected population is safe, effective, and comparable to other antiplatelet regimens. Therefore, ticlopidine is an attractive option for stent patients who cannot take aspirin.COMMENT BY MICHAEL H. CRAWFORD, MD
The critical role of platelets in coronary artery disease is exhibited in the saga of coronary stents. Early stent placement often resulted in acute thrombosis, so aggressive anticoagulant regimens were instituted. These caused excessive bleeding complications and did not prevent subacute stent thrombosis. Later, optimal stent deployment was refined by intravascular ultrasound, and stent thrombosis became less common. At this time, it became clear that antiplatelet therapy was superior to anticoagulation and the regimen of aspirin and ticlopidine after stent placement has become accepted. Newer studies have suggested that monotherapy with antiplatelet agents may be adequate.This study is of interest because it involved an unselected patient population, used several types of stents, and did not use intravascular ultrasound. Although there was no control group, the results seem acceptable, compared to the reported experiences with multidrug antiplatelet therapy. Also, the feared complication of neutropenia was not observed in this study, but serial white blood cell counts were only recommended to the primary physician; how many patients had these measurements is unknown.
One caveat is that, whenever possible, ticlopidine was started at four days before angioplasty and stenting and at an initial dose of 750 mg/d. Also, in patients not pretreated with ticlopidine, aspirin was co-administered for a few days to rapidly inhibit platelet activity. Thus, cognizance of the delay in onset of ticlopidine action may be important in this situation.
At this point, a randomized, controlled trial would need to be done to establish the safety and efficacy of ticlopidine monotherapy for stent patients and determine the optimal duration of therapy. Until such a study is done, ticlopidine is an alternative to those who cannot take aspirin.
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