Distinguishing in-stent thrombosis from in-stent restenosis

NATIONAL HARBOR, Md. — Prompt recognition of in-stent thrombosis is critical to initiate treatment, according to a presentation at Hospital Medicine 2019.

Distinguishing in-stent thrombosis from in-stent restenosis, is important because the outcomes of each condition are so different, said Jeffrey Trost, MD, associate professor of medicine at Johns Hopkins University School of Medicine.

The most valuable way to determine if a patient has in-stent thrombosis or in-stent restenosis, is to examine its physiology, he said. In-stent thrombosis is an acute condition which most commonly develops within 24 to 48 hours after the stent is placed. In addition, it is caused by thrombosis (usually a clot) in the stent. In-stent restenosis, however, “is not, by any means, an acute phenomenon,” usually occurring s within 6 to 12 months after implant, though it can  be detected years later. Furthermore, it is formed by excess neointimal hyperplasia, or scar tissue, within the stent.

In addition, the clinical manifestation of in-stent thrombosis is almost always acute coronary syndrome whereas there is a wider spectrum of manifestations for in-stent restenosis.

PCSK9 inhibitors have emerged as a valuable option for managing lipid levels in patients with acute coronary syndrome, he said.

According to Trost, “high intensity statin therapy is the cornerstone of lipid lowering” for secondary prevention in patients who have already had a cardiovascular event. As an addition to statin therapy, PCSK9 inhibitors can potentially reduce LDL levels “dramatically,” by more than 25%.

PCSK9 inhibitors are supplemental, and while “they do show benefit in patients with acute coronary syndrome, [hospitalists must] remember to consider them only for patients already on statins,” Trost said – by Melissa J. Webb

Reference:

Trost J. Updates in acute coronary syndrome. Presented at: Hospital Medicine 2019. March 25-27; National Harbor, Md.

Disclosures: Trost reports no relevant financial disclosures.