Abstract 16033: Prolonged Use of Clopidogrel and Risk of Death, Myocardial Infarction, and Major Bleeding 5 Years after Coronary Stenting in VA Patients with Chronic Kidney Disease
Current guidelines for drug-eluting (DES) and bare metal stents (BMS) include clopidogrel for up to one year after stenting. Patients with chronic kidney disease (CKD) have a higher risk of death, myocardial infarction, or major bleeding and may benefit from prolonging clopidogrel beyond 1 year.
Methods: We assessed all patients receiving a coronary stent between 2002-2006 in the National VA Healthcare system with baseline eGFR and not on hemodialysis. Clopidogrel use was extracted from the VA National Pharmacy database, and outcomes of death, myocardial infarction (MI), and major bleeding up to 5 years after PCI extracted from the VA National and Medicare databases. Outcomes were related to prolonged clopidogrel (> 12 mths) versus 12 or less mths using a landmark analysis starting 12 months after the index stent. We estimated Cox proportional hazards ratios (HR) for each outcome by DES and BMS, and CKD (eGFR < 60ml/min) or normal renal function (noCKD) (eGFR > 60ml/min).
Results: Of 18,931 patients receiving a coronary stent, 3987 (21%) had CKD and 14,944 (79%) had noCKD. Over an average four years after the 1 yr landmark, death or MI occurred in 651 (16.3%) patients with CKD and 1248 (8.4%) with noCKD. Both groups had similar rates of clopidogrel use beyond 1 yr [CKD: 1840 (46%), noCKD: 6684 (45%)] and DES [CKD: 2147 (54%), noCKD: 8260 (55%)]. In CKD patients, prolonged clopidogrel associated with a lower risk of death (HR=0.66, 95%CI=0.49, 0.88) and death or MI (HR=0.75, 95%CI=0.57, 0.99) only among patients with DES. Prolonged clopidogrel had no effect in CKD patients with BMS for death (HR=0.87, 95%CI=0.70, 1.08). In noCKD patients, prolonged clopidogrel associated with a lower risk of death, and death or MI for both DES (death HR=0.69, 95%CI=0.55, 0.86, death or MI HR=0.74, 95%CI=0.62, 0.89) and BMS (death HR=0.66, 95%CI=0.55, 0.80, death or MI HR=0.77, 95%CI=0.66, 0.90). There were no significant differences in major bleeding.
Conclusions: In this large unrestricted Veteran population, prolonged clopidogrel beyond 12 months associated with a lower risk of death or MI in patients with CKD receiving drug-eluting stents but not bare-metal stents. In contrast, prolonged clopidogrel in patients with noCKD related to a lower risk of death or MI with both stent types.
- © 2012 by American Heart Association, Inc.