Clopidogrel Duration and Post PCI Complications in Diabetics
Clopidogrel Duration and Post PCI Complications in Diabetics
Abstract & Commentary
By Andrew J. Boyle, MBBS, PhD
Source: Brar SS, et al. Long-term outcomes by Clopidogrel duration and stent type in a diabetic population with de novo coronary artery lesions. J Am Coll Cardiol. 2008;51: 2220-2227.
Patients with diabetes mellitus make up a substantial proportion of those undergoing percutaneous coronary intervention (PCI), and they are at higher risk for post-procedural complications. Recommendations for dual anti-platelet therapy have been extended to 12 months in patients receiving drug-eluting stents (DES), but the recommendation remains one month in patients receiving bare metal stents (BMS). The optimal duration of dual antiplatelet therapy in patients with diabetes remains unknown.
Brar et al performed a retrospective analysis of 749 consecutive diabetics undergoing successful PCI at a single center. These patients were divided according to what stent type they received (DES or BMS) and by the duration of clopidogrel use (< 6 months, 6-9 months and > 9 months). A comprehensive hospital and pharmacy database facilitated data acquisition on medication, dose, use, and duration. Data was also gained from a California state death database. An important strength of this study is that data on clopidogrel use was available for 95% of patients, and this was provided from pharmacy records, not patient self-reporting.
The rate of death or non-fatal MI was inversely proportional to duration of clopidogrel use. This combined endpoint occurred in 16.5%, 9.4%, and 3.2 % in the < 6 month, the 6-9 month and the > 9 month groups, respectively (p < 0.001). For death alone, the event rates were 10.0%, 4.3%, and 0.5%, respectively (p < 0.001).
Kaplan-Meier analysis showed a similar event rate between DES and BMS out to 180 days, but after 180 days, the event rate was lower in DES (p = 0.05). Multivariate analysis was used to adjust for adjunctive medical therapy with statins, ACE, ARB, beta-blockers, the number of stents deployed, stent diameter, and cumulative stent length. Compared to clopidogrel non-users with BMS, the hazard ratio of death or MI for clopidogrel users with DES, clopidogrel non-users with DES, and clopidogrel users with BMS were HR 0.22 (p = 0.005), HR 0.39 (p = 0.08), and HR 0.25 (p = 0.02), respectively. This suggests that, in their cohort, the duration of clopidogrel use is more important than the type of stent used in the risk of subsequent events. Brar et al conclude that, among diabetics with contemporary medical therapy, extended use of clopidogrel was associated with fewer adverse events in patients receiving either BMS or DES.
Commentary
It is important to note that this study only evaluated diabetics who had a health insurance plan. The results may not be generalizable to non-diabetics and uninsured patients. Furthermore, this was a retrospective analysis, not a prospective study. In addition, it was assumed that all filled prescriptions were actually taken by the patient, but this may not have been the case. Regardless, the data add to the growing literature that suggests prolonged clopidogrel therapy may help reduce events in all stented diabetic patients. However, definite recommendations for the appropriate duration of clopidogrel use in diabetics can only be drawn from prospective randomized trials.
Patients with diabetes mellitus make up a substantial proportion of those undergoing percutaneous coronary intervention (PCI), and they are at higher risk for post-procedural complications.Subscribe Now for Access
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