Coronary artery stent thrombosis: Clinical presentation and management... https://www.uptodate.com/contents/coronary-artery-stent-thrombosis-cli...

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Coronary artery stent thrombosis: Clinical presentation

and management
Author: Donald Cutlip, MD
Section Editors: Christopher P Cannon, MD, Stephan Windecker, MD
Deputy Editor: Gordon M Saperia, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature rev iew current through: Mar 2020. | This topic last updated: Oct 01, 2018.

INTRODUCTION

Coronary artery stents, particularly drug-eluting stents, are used in the majority of patients who
undergo percutaneous coronary intervention (PCI) to improve symptoms in patients with
obstructive coronary artery disease. They function both to prevent abrupt closure of the stented
artery soon after the procedure as well as to lower the need for repeat revascularization
compared to balloon angioplasty alone (formerly referred to as percutaneous transluminal
coronary angioplasty).

Stent thrombosis is an uncommon but serious complication of PCI with stenting. Most patients
present with an acute coronary syndrome, usually with ST-segment elevation on the
electrocardiogram. Its cause is total or subtotal thrombotic occlusion of a coronary artery by
thrombus that originates in or close to an intracoronary stent. This finding is seen at the time of
coronary angiography and it is necessary in most cases to secure the diagnosis. Death and
myocardial infarction are not infrequent complications of stent thrombosis.

This topic will discuss the presentation and management of and outcomes after acute coronary
artery stent thrombosis. Issues related to its incidence, timing, risk factors, and prevention are
discussed elsewhere. (See "Coronary artery stent thrombosis: Incidence and risk factors" and
"Long-term antiplatelet therapy after coronary artery stenting in stable patients".)

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DEFINITIONS

Although earlier clinical trials posed a problem for comparing stent thrombosis rates due to non-
standardized definition, since 2007, most trials have adopted the criteria and classification
proposed by the Academic Research Consortium (ARC) [1].

● Definite – Angiographic confirmation of a thrombus that originates in the stent or in the

segment 5 mm proximal or distal to the stent, with or without vessel occlusion, which is
associated with acute onset of ischemic symptoms at rest or electrocardiographic (ECG)
signs of acute ischemia or typical rise and fall of in cardiac biomarkers within 48 hours of
angiography or pathologic confirmation of stent thrombosis determined at autopsy or from
tissue obtained following thrombectomy.

● Probable – Unexplained death occurring within 30 days after the index procedure, or a
myocardial infarction occurring at any time after the index procedure that was documented
by ECG or imaging to occur in an area supplied by the stented vessel in the absence of
angiographic confirmation of stent thrombosis or other culprit lesion.

● Possible – Unexplained death occurring more than 30 days after the index procedure.

In the discussion that follows, studies using definitions other than ARC will be noted.

CLINICAL PRESENTATION AND DIAGNOSIS

Patients with stent thrombosis usually present with an acute coronary syndrome (ACS; unstable
angina, non-ST elevation myocardial infarction [NSTEMI], or ST-elevation MI [STEMI]). (See "Initial
evaluation and management of suspected acute coronary syndrome (myocardial infarction,
unstable angina) in the emergency department".)

In most cases, patients present with criteria for the diagnosis of acute STEMI [2]. (See
"Diagnosis of acute myocardial infarction".) In a report from the United States CathPCI Registry,
among almost 7100 cases of stent thrombosis identified during a 16-month period,
approximately 60 percent presented with STEMI, 23 percent with NSTEMI, and 17 percent with
unstable angina [3]. Patients with early stent thrombosis (<1 month after stent placement) are
somewhat more likely to develop cardiogenic shock than those with late (1 to 12 months) or very
late (>12 months) stent thrombosis [3]. (See "Clinical manifestations and diagnosis of
cardiogenic shock in acute myocardial infarction", section on 'Clinical presentation'.)

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At the time of coronary angiography, most patients have complete thrombotic occlusion (TIMI flow
grade 0) of the involved vessel (table 1) [3]. The culprit lesion is more common in the left anterior
descending artery (48 percent) in patients with early and late stent thrombosis, whereas the right
coronary artery (38 percent) is more commonly involved in cases of very late stent thrombosis
[3].

Stent thrombosis should be considered in any patient who presents with an ACS after
percutaneous coronary intervention (PCI) with stenting, particularly within the past year. In the
CathPCI Registry, 1.8 percent of all PCI for ACS were attributable to stent thrombosis [3]. In a
2012 report from two hospitals in Minneapolis, Minnesota, USA, nearly 11 percent of all STEMI
was attributable to definite stent thrombosis according to the Academic Research Consortium
(ARC) criteria [4].

While the possibility of stent thrombosis should be considered in any patient who presents with
ACS after stent placement, there is no information from the history, physical examination, or
electrocardiogram (ECG) that can be used to clearly discriminate between stent thrombosis and
ACS due to ischemia from a lesion(s) not related to prior stent placement. In the presence of ST-
elevation or other changes suggestive of target (stented) vessel ischemia, the suspicion for
stent thrombosis should be higher. Such an event would be classified as probable stent
thrombosis by the ARC criteria unless angiography confirms another culprit. We accept the ARC
criteria for the diagnosis of stent thrombosis; these criteria include categories of definite,
probable, and possible [1]. Patients who have unexplained death after stent placement for which
stent thrombosis is a reasonable cause are categorized as having either probable or possible
stent thrombosis. (See "Coronary artery stent thrombosis: Incidence and risk factors", section on
'Definitions'.)

The definition of definite stent thrombosis is as follows: angiographic or tissue (from

thrombectomy at the time of angiography) confirmation of a thrombus that originates in the stent
or in the segment 5 mm proximal or distal to the stent, with or without vessel occlusion, which is
associated with acute onset of ischemic symptoms at rest or ECG signs of acute ischemia or
typical rise and fall of cardiac biomarkers within 48 hours of angiography. Definite stent
thrombosis may also be determined by pathologic confirmation of stent thrombosis at the time
of an autopsy. (See "Long-term antiplatelet therapy after coronary artery stenting in stable
patients", section on 'Duration of DAPT treatment'.)

While the (incidental) finding of thrombus within a stent in a patient without clinical findings is
possible, this is likely infrequent. Most of these individuals will have an ACS or have an elevated
troponin value.

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MANAGEMENT

Patients with ST elevation myocardial infarction (STEMI) due to stent thrombosis should be
managed with primary percutaneous coronary intervention, although restoration of blood flow
with intracoronary fibrinolysis has been used [5]. (See "Primary percutaneous coronary
intervention in acute ST elevation myocardial infarction: Periprocedural management".)

Since stents are often placed in proximal segments of major coronary arteries, acute thrombotic
occlusion presents as severe ischemia or MI, often STEMI [5-7]. The approach to the
management of patients with unstable angina or acute MI is discussed elsewhere. (See
"Overview of the acute management of ST-elevation myocardial infarction" and "Overview of the
acute management of non-ST elevation acute coronary syndromes".)

The management of patients with stent thrombosis is similar to that for other patients with an
acute coronary syndrome (ACS). However, as outcomes in these patients appear to be worse
than in individuals with ACS due to plaque rupture in a native coronary artery, it is critically
important that the time to reperfusion be as short as possible. (See 'Compared to de novo
coronary thrombosis' below.) While a non-urgent invasive or a conservative strategy may be
reasonable for some patients with unstable angina or non-ST elevation MI who have not had
prior stenting, urgent coronary angiography should be considered for most patients in whom the
diagnosis of stent thrombosis has been considered.

Periprocedural considerations — Recanalization of the occluded artery is possible in over 95

percent of cases. Manual thrombus aspiration can be used in this setting [3] and, in one study,
was associated with greater epicardial and microvascular myocardial perfusion [8]. Similar to
patients with STEMI due to de novo thrombosis, we perform thrombectomy in most cases of
stent thrombosis. (See "Suboptimal reperfusion after primary percutaneous coronary
intervention in acute ST elevation myocardial infarction", section on 'Thrombectomy'.)

In some cases, contributing factors such as suboptimal stent apposition or prior placement of
an undersized stent are present. We perform intravascular ultrasound in most cases of stent
thrombosis and use this information for subsequent stent sizing and to confirm complete stent
apposition. (See "Coronary artery stent thrombosis: Incidence and risk factors", section on 'Risk
factors'.)

Some experts feel that new stent implantation should be avoided unless there is a clear
indication such as a flow-limiting dissection. However, in many cases, we repeat stent
placement unless thrombus aspiration and balloon angioplasty yield an optimal result. We

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generally guide the decision making about the type of stent placement (bare metal versus drug-
eluting) in a manner similar to patients with de novo stenting, with drug-eluting stents preferred if
the patient is able to comply with the recommended duration of dual antiplatelet therapy (DAPT).
(See "Long-term antiplatelet therapy after coronary artery stenting in stable patients", section on
'Summary and recommendations'.)

The periprocedural antithrombotic approach, including the use of parenteral antiplatelet and
anticoagulant therapies, does not differ from that recommended for patients with acute STEMI.
(See "Anticoagulant therapy in acute ST-elevation myocardial infarction" and "Antiplatelet agents
in acute ST-elevation myocardial infarction".)

Long-term antiplatelet therapy — Poor compliance with the recommendation for DAPT may be
the primary cause of development of stent thrombosis. (See "Coronary artery stent thrombosis:
Incidence and risk factors", section on 'Risk factors'.) In addition, resistance to clopidogrel may
be an important contributing factor in many cases. The optimal approach to antiplatelet therapy
after stent thrombosis in patients who demonstrate clopidogrel nonresponse on platelet testing,
or a genetic predisposition to it, is not known. (See "Clopidogrel resistance and clopidogrel
treatment failure", section on 'Definitions'.)

In patients who present with stent thrombosis while on clopidogrel, it is likely the risk of recurrent
stent thrombosis is increased. While no trials of alternate antiplatelet regimens, such as
switching to prasugrel or ticagrelor or higher-dose clopidogrel, have been performed in these
patients, we believe that the benefit from the use of more potent antiplatelet therapy outweighs
the increase in risk of bleeding in most patients. Therefore, we suggest discharging the patient
on prasugrel 10 mg daily or ticagrelor 90 mg twice daily, in addition to aspirin. The minimum
duration of DAPT should be one year, with longer courses for patients who are tolerating such
therapy.

Similarly, for patients who present with stent thrombosis after completing the recommended
duration of treatment with clopidogrel, the optimal preventative antiplatelet strategy is unknown.
We suggest initiating prasugrel 10 mg daily or ticagrelor 90 mg twice daily rather than restarting
clopidogrel and continuing DAPT for a minimum of one year or longer in patients tolerating this
regimen. However, in patients who will not receive either prasugrel or ticagrelor, clopidogrel 75
mg daily (in addition to aspirin) should be restarted.

In patients who have sustained stent thrombosis, the optimal duration of DAPT is unknown.
While we suggest continuing DAPT for more than one year in all patients with stent thrombosis,
continual monitoring of the relative benefits and risks (primarily the risk of bleeding) is
necessary.

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OUTCOMES

MI and death — The following studies highlight high rates of myocardial infarction (MI) and death
after acute stent thrombosis:

● Among patients with an acute coronary syndrome and angiographically-confirmed (definite)

stent thrombosis in a pooled analysis, the 30-day rate of MI was 60 percent [6].

● The 30-day mortality rates after stent thrombosis are 7 percent for angiographically
confirmed and 19 percent for clinically identified stent thrombosis for bare metal stents
(BMS) based upon pooled clinical trial data [6] and 15 percent with drug-eluting stents
(DES) based upon a large real-world registry [9]. One study of 7315 stent thrombotic events
found that in-hospital mortality was higher in patients with early stent thrombosis (up to 30
days after stent placement) compared with late (30 days to one year) and very late stent
(after one year) thrombosis (7.9 versus 3.8 and 3.6 percent; p <0.01) [3].

● Six-month mortality is between 20 and 25 percent among survivors of stent thrombosis [10].
Some studies have reported higher six-month mortality rates after stent thrombosis with
DES compared to BMS (17 to 45 percent [11-14] and 9 to 21 percent [5,6], respectively).
However, other studies have shown equivalent mortality [14]. Predictors of six-month
mortality include very late stent thrombosis, implantation of a stent during percutaneous
coronary intervention (PCI) for stent thrombosis, and failure to achieve optimal angiographic
reperfusion [14].

● Mortality at one year after definite DES thrombosis is between 10 and 20 percent [10,15-17].

● Longer-term mortality (450 days) after definite stent thrombosis was 22 percent in the
TRITON-TIMI 38 trial of acute coronary syndrome patients who were randomly assigned to
either clopidogrel or prasugrel and then underwent PCI with stenting [18].

● The overall rates of death and MI at four years were 31 and 83 percent, respectively, after
definite or possible stent thrombosis (Academic Research Consortium definition) in a
pooled analysis of eight randomized trials comparing DES to BMS [19]. The outcomes with
DES and BMS stent thrombosis were combined.

Recurrent stent thrombosis — Although not well studied, the incidence of recurrent stent
thrombosis is relatively high. In a review of 95 patients with BMS thrombosis, 11 patients (12
percent) had recurrent stent thrombosis at six months [5]. In a registry of DES, recurrence was
4.6 percent at one year [15]. In a report of 431 patients in the Dutch stent thrombosis registry, the

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cumulative incidence of definite or probable recurrent stent thrombosis was 20.1 percent at
three years [16].

Angiographic predictors of recurrent stent thrombosis include a larger post-procedural vessel

diameter and a larger residual thrombus burden [20].

Compared to de novo coronary thrombosis — ST-elevation MI (STEMI) is characterized by

intraluminal thrombus irrespective of whether the initial event is de novo (in association with
plaque rupture) or stent related. However, clinical outcomes appear worse with the latter [6,10].
(See "Long-term antiplatelet therapy after coronary artery stenting in stable patients", section on
'Duration of DAPT treatment'.)

In an attempt to understand this difference, clinical and angiographic outcomes in patients with
STEMI due to stent thrombosis (n = 92) and de novo coronary thrombosis (n = 98) were
compared in a retrospective study of patients who underwent primary PCI for STEMI [10]. The
following findings were noted in patients with stent thrombosis compared to those with de novo
coronary thrombosis:

● In-hospital major adverse cardiovascular and cerebrovascular events were significantly

higher (22.6 versus 9.2 percent), including a significantly higher in-hospital death rate (17.4
versus 7.1 percent). However, there were no differences at six-month follow-up.

● Successful reperfusion using angiographic criteria was significantly lower (80.4 versus 96.9
percent)

In another study of approximately 3300 patients with STEMI between 2002 and 2010, mortality
was similar between those with STEMI due to stent thrombosis compared to those with de novo
coronary thrombosis [4]. However, the rate of reinfarction was higher in those with stent
thrombosis.

In a cohort of 2464 individuals with STEMI treated with primary PCI, the mid-term outcomes of
those with angiographically proven stent thrombosis (3 percent) were compared to those with a
primary coronary artery event (97 percent) [21]. At six months, those with stent thrombosis were
shown to have significantly higher rates of non-fatal MI and restenosis/reocclusion (54 versus 17
and 10 versus 1 percent), while the rate of death was not significantly different (12 versus 8
percent).

INTRAPROCEDURAL STENT THROMBOSIS

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The importance of intraprocedural stent thrombosis (IPST) as a risk factor for subsequent
mortality and recurrent thrombosis has been highlighted [22,23]. IPST was defined as the
development of occlusive or non-occlusive new or increasing thrombus in or adjacent to a
recently implanted stent before the percutaneous coronary intervention (PCI) procedure is
completed. IPST is not included in the Academic Research Consortium (ARC) definitions and
thus its presentation and management are not evaluated uniformly in studies of stent
thrombosis [22,23]. (See "Coronary artery stent thrombosis: Incidence and risk factors", section
on 'Definitions' and "Coronary artery stent thrombosis: Incidence and risk factors", section on
'Intraprocedural stent thrombosis'.)

In a study of over 10,000 individuals who underwent PCI with stenting, patients with IPST had a
higher rate of composite ischemia (death, MI, ischemia-driven revascularization, or new-onset
out-of-laboratory stent thrombosis) at 48 hours and 30 days compared to those without IPST
(29.2 versus 4.5 and 31.5 versus 5.7 percent, respectively) [23]. The finding of a significantly
higher rate of ARC definite or probable stent thrombosis at 30 days has been noted in other
studies [22]. Most cases were in the setting of non-ST elevation acute coronary syndrome or ST
elevation myocardial infarction. The impact of thrombus burden and the no-reflow phenomenon
may be important contributors. While clearly distinguished from classic stent thrombosis after a
successful procedure, the known adverse consequences of procedural complications remain
important and ongoing studies are needed to assess methods for improved procedural
success in these high-risk patients.

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Percutaneous coronary
intervention".)

SUMMARY AND RECOMMENDATIONS

● Stent thrombosis is an uncommon but serious complication of percutaneous coronary

intervention with stenting. Most patients present with an acute coronary syndrome (ACS),
usually with ST-segment elevation on the electrocardiogram. Its cause is total or subtotal
thrombotic occlusion of a coronary artery by thrombus that originates in or close to an
intracoronary stent. This finding is seen at the time of coronary angiography and it is
necessary, in most cases, to secure the diagnosis. Death and myocardial infarction are not

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infrequent complications of stent thrombosis. (See 'Clinical presentation and diagnosis'

above.)

● In general, the acute management of patients with stent thrombosis is similar to that for
other patients with an ACS. Important points include considering the diagnosis in any
patient ACS with prior stent placement and a rapid attempt to restore vessel patency. (See
'Management' above.)

● For patients diagnosed with stent thrombosis while on clopidogrel, we suggest switching
the patient to prasugrel 10 mg daily or ticagrelor 90 mg twice daily (Grade 2C). (See 'Long-
term antiplatelet therapy' above.)

● For patients diagnosed with stent thrombosis who have completed the minimum
recommended course of clopidogrel, we suggest starting prasugrel 10 mg daily or
ticagrelor 90 mg twice daily, rather than restarting clopidogrel 75 mg daily (Grade 2C). (See
'Long-term antiplatelet therapy' above.)

● In patients with stent thrombosis, irrespective of whether they were or were not on dual
antiplatelet therapy (DAPT) at the time of the event, we suggest DAPT for a minimum of one
year after the event, rather than shorter periods of time (Grade 2C). The ultimate duration of
DAPT will require continual assessment of the benefits and risks (in particular, bleeding
risk).

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REFERENCES

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2. Holmes DR Jr, Kereiakes DJ, Garg S, et al. Stent thrombosis. J Am Coll Cardiol 2010;
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3. Armstrong EJ, Feldman DN, Wang TY, et al. Clinical presentation, management, and
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4. Brodie BR, Hansen C, Garberich RF, et al. ST-segment elevation myocardial infarction

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resulting from stent thrombosis: an enlarging subgroup of high-risk patients. J Am Coll

Cardiol 2012; 60:1989.

5. Wenaweser P, Rey C, Eberli FR, et al. Stent thrombosis following bare-metal stent
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6. Cutlip DE, Baim DS, Ho KK, et al. Stent thrombosis in the modern era: a pooled analysis of
multicenter coronary stent clinical trials. Circulation 2001; 103:1967.

7. Fischman DL, Leon MB, Baim DS, et al. A randomized comparison of coronary-stent
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8. Mahmoud KD, Vlaar PJ, van den Heuvel AF, et al. Usefulness of thrombus aspiration for the
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9. Ong AT, Hoye A, Aoki J, et al. Thirty-day incidence and six-month clinical outcome of
thrombotic stent occlusion after bare-metal, sirolimus, or paclitaxel stent implantation. J
Am Coll Cardiol 2005; 45:947.

10. Chechi T, Vecchio S, Vittori G, et al. ST-segment elevation myocardial infarction due to early
and late stent thrombosis a new group of high-risk patients. J Am Coll Cardiol 2008;
51:2396.

11. Iakovou I, Schmidt T, Bonizzoni E, et al. Incidence, predictors, and outcome of thrombosis
after successful implantation of drug-eluting stents. JAMA 2005; 293:2126.

12. Ong AT, McFadden EP, Regar E, et al. Late angiographic stent thrombosis (LAST) events
with drug-eluting stents. J Am Coll Cardiol 2005; 45:2088.

13. Mishkel GJ, Moore AL, Markwell S, et al. Long-term outcomes after management of
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14. Burzotta F, Parma A, Pristipino C, et al. Angiographic and clinical outcome of invasively
managed patients with thrombosed coronary bare metal or drug-eluting stents: the
OPTIMIST study. Eur Heart J 2008; 29:3011.

15. de la Torre-Hernández JM, Alfonso F, Hernández F, et al. Drug-eluting stent thrombosis:

results from the multicenter Spanish registry ESTROFA (Estudio ESpañol sobre

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TROmbosis de stents FArmacoactivos). J Am Coll Cardiol 2008; 51:986.

16. van Werkum JW, Heestermans AA, de Korte FI, et al. Long-term clinical outcome after a first
angiographically confirmed coronary stent thrombosis: an analysis of 431 cases.
Circulation 2009; 119:828.

17. Kimura T, Morimoto T, Kozuma K, et al. Comparisons of baseline demographics, clinical

presentation, and long-term outcome among patients with early, late, and very late stent
thrombosis of sirolimus-eluting stents: Observations from the Registry of Stent
Thrombosis for Review and Reevaluation (RESTART). Circulation 2010; 122:52.

18. Wiviott SD, Braunwald E, McCabe CH, et al. Intensive oral antiplatelet therapy for reduction
of ischaemic events including stent thrombosis in patients with acute coronary syndromes
treated with percutaneous coronary intervention and stenting in the TRITON-TIMI 38 trial: a
subanalysis of a randomised trial. Lancet 2008; 371:1353.

19. Mauri L, Hsieh WH, Massaro JM, et al. Stent thrombosis in randomized clinical trials of
drug-eluting stents. N Engl J Med 2007; 356:1020.

20. Porto I, Burzotta F, Parma A, et al. Angiographic predictors of recurrent stent thrombosis
(from the Outcome of PCI for stent-ThrombosIs MultIcentre STudy [OPTIMIST]). Am J
Cardiol 2010; 105:1710.

21. Parodi G, Memisha G, Bellandi B, et al. Effectiveness of primary percutaneous coronary

interventions for stent thrombosis. Am J Cardiol 2009; 103:913.

22. Brener SJ, Cristea E, Kirtane AJ, et al. Intra-procedural stent thrombosis: a new risk factor
for adverse outcomes in patients undergoing percutaneous coronary intervention for acute
coronary syndromes. JACC Cardiovasc Interv 2013; 6:36.

23. Généreux P, Stone GW, Harrington RA, et al. Impact of intraprocedural stent thrombosis
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Topic 87310 Version 7.0

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GRAPHICS

Thrombolysis in myocardial infarction (TIMI) flow grading system

Grade 0 - Complete occlusion of the infarct-related artery

Grade 1 - Some penetration of contrast material beyond the point of obstruction but without perfusion of the distal
coronary bed

Grade 2 - Perfusion of the entire infarct vessel into the distal bed but with delayed flow compared with a normal
artery

Grade 3 - Full perfusion of the infarct vessel with normal flow

From Chesebro JH, Knatterud G, Roberts R, et al. Thrombolysis in Myocardial Infarction (TIMI) Trial, Phase I: A comparison
between intravenous tissue plasminogen activator and intravenous streptokinase. Clinical findings through hospital
discharge. Circulation 1987; 76:142.

Graphic 51941 Version 3.0

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Contributor Disclosures
Donald Cutlip, MD Consultant/Advisory Boards: CeloNova [Coronary artery stent]. Christopher P
Cannon, MD Grant/Research/Clinical Trial Support: Amgen [Lipids (Evolocumab), heart failure (Ivabradine)];
Boehringer-Ingelheim [AF (Dabigatran), DM (Empaglifozin, Linagliptin)]; Bristol-Myers Squibb [AF (Apixaban)];
Daiichi Sankyo [AF (Edoxaban)]; Janssen [AF (Rivaroxaban), DM (Canagliflozin)]; Merck [Lipids (Ezetimibe),
DM (Ertugliflozin, Sitaglipitin)]; Pfizer ([AF (Apixaban), DM (Ertugliflozin), lipids (Atorvastatin)].
Consultant/Advisory Boards: Alnylam [Lipids (Inclisiran)]; Amarin [Lipids (Vascepa icosapent ethyl)]; Amgen
[Lipids (Evolocumab), heart failure (Ivabradine)]; BI [AF (Dabigatran), DM (Empaglifozin, Linagliptin)]; Bristol-
Myers Squibb [AF (Apixaban)]; Janssen [AF (Rivaroxaban), DM (Canagliflozin)]; Kow a [Lipids (Pitavastatin)];
Lipimedix [Lipids]; Merck [Lipids (Ezetimibe), DM (Ertugliflozin, Sitaglipitin)]; Pfizer [AF (Apixaban), DM
(Ertugliflozin), lipids (Atorvastatin)]; Sanofi [Lipids (Alirocumab), ACS (Clopidogrel)], diabetes (Lixisenatide,
Sotagliflozin); Aegerion [lipids (lomitapide)]; HLS Therapeutics [lipids (Vascepa icosapent ethyl)]; Applied
Therapeutics [lipids]; Ascendia [lipids]; Corvidia [lipids]; Innovent [lipids]. Stephan Windecker,
MD Grant/Research/Clinical Trial Support: Boston Scientific [General Cardiology]; Abbott [Interventional
Cardiology (Xience)]; Amgen [Atherosclerosis (Evelocumab)]; Biotronik [Stents (ORSIRO)]; Edw ards
[Interventional cardiology (stent imaging)]; Bayer AG [General cardiology (anticoagulation)]; Bristol Myers
Squibb [(General Cardiology (anticoagulant)]; Sinomed [Interventional Cardiology (stents)]; Polares
[Interventional Cardiology (TMVR)]; CSL Behring [General Cardiology (Drug)]. Gordon M Saperia,
MD Nothing to disclose

Contributor disclosures are review ed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.

Conflict of interest policy

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