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Outcomes with prolonged clopidogrel therapy after coronary stenting in patients with chronic kidney disease
Omar K Siddiqi1, Kyle J Smoot2, Alyssa B Dufour3
1Cardiovascular Division, Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts, USA Cardiovascular Division, Boston Medical Center, Boston, Massachusetts, USA.
Insights
Patients with chronic kidney disease (CKD) face higher risks after percutaneous coronary interventions (PCI). Prolonging clopidogrel therapy beyond 12 months may reduce death or myocardial infarction (MI) risk, particularly for those receiving drug-eluting stents (DES).
Area of Science:
- Cardiology
- Nephrology
- Pharmacology
Background:
- Patients with chronic kidney disease (CKD) exhibit elevated risks of adverse cardiovascular events, including death and myocardial infarction (MI), following percutaneous coronary interventions (PCI).
- Standard dual antiplatelet therapy (DAPT) duration post-PCI is typically 12 months, but optimal duration for CKD patients remains under investigation.
Purpose of the Study:
- To evaluate the efficacy of prolonged dual antiplatelet therapy (DAPT) beyond 12 months in mitigating adverse outcomes for patients with CKD undergoing PCI with drug-eluting stents (DES) or bare-metal stents (BMS).
- To assess the impact of extended clopidogrel use on mortality, MI, and repeat revascularization rates in CKD patients post-PCI.
Main Methods:
- A retrospective study of Veterans undergoing PCI between 2002-2006, classifying patients by CKD status (eGFR <60 mL/min) or normal renal function.
- Landmark analyses from 12 months post-PCI were conducted using Cox proportional hazards models to compare outcomes between prolonged clopidogrel use (>12 months) and standard duration (≤12 months).
Main Results:
- CKD patients had significantly higher risks of death or MI compared to those with normal renal function, both after DES and BMS implantation.
- In CKD patients treated with first-generation DES, prolonged clopidogrel use (>12 months) was associated with a significant reduction in the composite outcome of death or MI, and also reduced all-cause death.
- Prolonged clopidogrel therapy did not demonstrate a significant effect on repeat revascularization rates in CKD patients receiving DES or BMS.
Conclusions:
- Extending clopidogrel therapy beyond 12 months may offer a survival benefit by reducing the risk of death or MI in CKD patients who received first-generation DES.
- These findings suggest a personalized approach to DAPT duration in CKD patients post-PCI, considering stent type and individual risk factors.
Objectives:
Patients with chronic kidney disease (CKD) are at high risk of death or myocardial infarction (MI) after percutaneous coronary interventions (PCI). We assessed whether prolonged dual antiplatelet therapy beyond the recommended 12 months may prevent adverse outcomes in patients with CKD receiving drug-eluting stents (DES) or bare-metal stents (BMS).
Methods:
We studied all Veterans receiving PCI with BMS or first-generation DES in the Veterans Affairs (VA) Healthcare System between 2002 and 2006, classified by CKD (estimated glomerular filtration rate <60 mL/min) or normal renal function. We used landmark analyses from 12 months after PCI with Cox proportional hazards multivariable and propensity-adjusted models to assess the effect of prolonged clopidogrel (more than 12 months) versus 12 months or less after PCI on clinical outcomes from 1 year to 4 years after PCI.
Results:
Of 23 042 eligible subjects receiving PCI, 4880 (21%) had CKD. Compared with normal renal function, patients with CKD had higher risks of death or MI 1-4 years after DES (21% vs 12%, HR=1.75; 95% CI 1.51 to 2.04) or BMS (28% vs 15%, HR=2.10; 95% CI 1.90 to 2.32). In patients with CKD receiving DES, clopidogrel use of more than 12 months after PCI was associated with lower risks of death or MI (18% vs 24%, HR=0.74; 95% CI 0.58 to 0.95), and death (15% vs 23%, HR=0.61; 95% CI 0.47 to 0.80), but had no effect on repeat revascularisation 1-4 years after PCI.
Conclusions:
In patients with CKD, prolonging clopidogrel beyond 12 months after PCI may decrease the risk of death or MI only in patients receiving first-generation DES. These results support a patient-tailored approach to prolonging clopidogrel after PCI.
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