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Outcomes with prolonged clopidogrel therapy after coronary stenting in patients with chronic kidney disease
  1. Omar K Siddiqi1,2,
  2. Kyle J Smoot1,3,
  3. Alyssa B Dufour1,3,4,5,
  4. Kelly Cho1,3,4,
  5. Melissa Young1,3,
  6. David R Gagnon1,3,6,
  7. Samantha Ly1,
  8. Sara Temiyasathit1,
  9. David P Faxon1,4,7,
  10. J Michael Gaziano1,3,4,7,
  11. Scott Kinlay1,4,7
  1. lCardiovascular Division, Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts, USA
  2. 2Cardiovascular Division, Boston Medical Center, Boston, Massachusetts, USA
  3. 3MAVERIC, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA
  4. 4Harvard Medical School, Boston, Massachusetts, USA
  5. 5Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
  6. 6Boston University School of Public Health, Boston, Massachusetts, USA
  7. 7Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
  1. Correspondence to Dr Scott Kinlay, Cardiovascular Division, VA Boston Healthcare System, 1400 VFW Parkway, West Roxbury, MA 02132, USA; scott.kinlay{at}va.gov

Abstract

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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