Diabetes Mellitus and Prevention of Late Myocardial Infarction After Coronary Stenting in the Randomized Dual Antiplatelet Therapy Study

Abstract

Background— Patients with diabetes mellitus (DM) are at high risk for recurrent ischemic events after coronary stenting. We assessed the effects of continued thienopyridine among patients with DM participating in the Dual Antiplatelet Therapy (DAPT) Study as a prespecified analysis. Methods and Results— After coronary stent placement and 12 months treatment with open-label thienopyridine plus aspirin, 11 648 patients free of ischemic or bleeding events and who were medication compliant were randomly assigned to continued thienopyridine or placebo, in addition to aspirin, for 18 more months. After randomization, patients with DM (n=3391), in comparison with patients without DM (n=8257), had increased composite outcome of death, myocardial infarction (MI), or stroke (6.8% versus 4.3%, P <0.001), increased death (2.5% versus 1.4%, P <0.001), and MI (4.2% versus 2.6%, P <0.001). Among patients with DM, in a comparison of continued thienopyridine versus placebo, rates of stent thrombosis were 0.5% versus 1.1%, P =0.06, and rates of MI were 3.5% versus 4.8%, P =0.058; and among patients without DM the rates were 0.4% versus 1.4%, P <0.001 (stent thrombosis, P interaction=0.21) and 1.6% versus 3.6%, P <0.001 (MI, P interaction=0.02). Bleeding risk with continued thienopyridine was similar among patients with or without DM (interaction P =0.61). Conclusions— In patients with DM, continued thienopyridine beyond 1 year after coronary stenting is associated with reduced risk of MI, although this benefit is attenuated in comparison with patients without DM. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00977938.

2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS

“…242 However, there was no signal for heterogeneity with respect to the concomitant presence of diabetes mellitus across all other ischaemic or safety endpoints. Finally, no difference with respect to the presence or absence of diabetes was observed for the primary efficacy endpoint in the PEGASUS study (P int = 0.99).…”

Short term versus long term dual antiplatelet therapy after implantation of drug eluting stent in patients with or without diabetes: systematic review and meta-analysis of individual participant data from randomised trials

“…46 The recent dedicated subanalysis of the DAPT trial showed that prolonged DAPT reduced the risk of myocardial infarction, but this benefit was attenuated in patients with diabetes compared with those without diabetes. 47 Similarly, in the DES-LATE, patients with diabetes showed a trend towards benefit from interrupting DAPT at 12 months, although the P value for interaction was borderline (P=0.07). 48 Conversely, other trials, includ-ing OPTIMIZE, 26 RESET, 28 I-LOVE-IT 2, 37 ISAR-SAFE, 38 ARCTIC Interruption, 49 and the recently published IVUS-XPL 40 did not show significant heterogeneity between subgroups with and without diabetes.…”

Duration of Dual Antiplatelet Therapy in Patients with CKD and Drug-Eluting Stents

“…Both presence of diabetes and the degree of diabetic control can affect clopidogrel metabolism, as well as platelet inhibition by clopidogrel (36,37). Benefit from extended DAPT has been shown to be attenuated in patients with diabetes compared with individuals without diabetes mellitus (38). Furthermore, body mass index is often higher among patients with diabetes mellitus and may affect the degree of platelet inhibition by clopidogrel (39,40).…”