Outcomes with prolonged clopidogrel therapy after coronary stenting in patients with chronic kidney disease

Siddiqi, Omar K.; Smoot, Kyle J.; Dufour, Alyssa B.; Cho, Kelly; Young, Melissa; Gagnon, David; Ly, Sophia; Temiyasathit, Sara; Faxon, David P.; Gaziano, J. Michael; Kinlay, Scott

doi:10.1136/heartjnl-2014-307168

Cited by 27 publications

(30 citation statements)

References 34 publications

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“…Between April 2002 and September 2006, 5,760 Veterans in the Veterans Health Administration (VA) received percutaneous coronary interventions (PCIs) per year [3]; this number doubled to 10,715 per year in the period from October 2007 to September 2013 [4]. Thrombotic CV events in CKD patients portend poor prognosis such that at 1-year post-PCI, Veterans with CKD had a 75% higher risk of death or thrombotic CV event compared to Veterans with normal kidney function, adjusted hazard ratio of 1.75 (95% CI 1.51-2.04) [3]. Veterans with CKD experience increased rates of hospitalization, adverse clinical outcomes, high disease burden to healthcare services, and high health care-related costs [5].…”

Section: Introductionmentioning

confidence: 99%

Prevalence of Chronic Kidney Disease, Thrombotic Cardiovascular Events, and Use of Oral P2Y<sub>12</sub> Inhibitors among Veterans

Singh¹,

Raghavan²,

Williams³

et al. 2018

Am J Nephrol

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Background: Contemporary prevalence of chronic kidney disease (CKD) and thrombotic cardiovascular (CV) events remains unclear in Veterans enrolled in the Veterans Affairs Health Care System (VA) care. Although oral P2Y₁₂ inhibitors (P2Y12i) are increasingly being prescribed to this patient population, the overall prescription trend for P2Y12i remains unclear. Methods: Using national VA corporate warehouse data, we used International Classification of Diseases-9 codes to identify Veterans with CKD, dialysis-dependent CKD, and CV events. VA pharmacy data were used to count P2Y12i prescriptions for the federal fiscal years (FY) 2011 through 2015. Results: The period prevalence of Veterans with CKD was 378,233 (6.1%). The point prevalence of CKD increased by 49% from 132,979 (2.30%) in FY11 to 213,444 (3.42%) in FY15. The period prevalence of Veterans with dialysis-dependent CKD was 150,298 (2.4%). In all, 128,703 (56.7%) CV events occurred in Veterans with CKD. Veterans with CKD were given 50.1% of prescriptions for clopidogrel, 49.3% for prasugrel, and 60.4% for ticagrelor. In this patient population, year-to-year increases in P2Y12i prescriptions were observed with a dramatic increase in ticagrelor prescriptions. Conclusion: CKD is common among Veterans and its true prevalence is likely being underestimated. The prevalence of dialysis-dependent CKD is higher among Veterans than the non-Veteran US population. CV events are widely co-prevalent and these patients are commonly prescribed P2Y12i. The recent increase in ticagrelor prescriptions in this patient population and large cost differences between the 3 P2Y12i underline the need for future studies to identify the preferred P2Y12i for these patients.

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Section: Introductionmentioning

confidence: 99%

Prevalence of Chronic Kidney Disease, Thrombotic Cardiovascular Events, and Use of Oral P2Y<sub>12</sub> Inhibitors among Veterans

Singh¹,

Raghavan²,

Williams³

et al. 2018

Am J Nephrol

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“…More recently, there is an increasing interest in the study of interventions in CKD patients. Antiplatelet therapy beyond 1 year after PCI with clopidogrel in patients with CKD was associated with a lower risk of death or MI [22] . In a subgroup analysis of the PLATO trial, patients with CKD treated with ticagrelor had a greater reduction in adverse events and mortality compared with non-CKD patients [23] .…”

Section: Discussionmentioning

confidence: 99%

Impact of Mild-to-Moderate Chronic Kidney Disease on One Year Outcomes after Percutaneous Coronary Intervention

Grandjean-Thomsen

Marley²,

Shadbolt³

et al. 2017

Nephron

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Background/Aim: Patients with severe chronic kidney disease (CKD) have a higher risk of adverse events after percutaneous coronary intervention (PCI). There is conflicting evidence regarding the benefit of drug-eluting stents (DES) in patients with CKD. This study is aimed at assessing the effect of mild-to-moderate CKD on PCI outcomes, and determining if DES reduce adverse events amongst these patients. Method: We used our PCI database to determine demographic, procedural and outcome variables for 1960 consecutive patients (October 2009-October 2012). Kidney function was measured by the estimated glomerular filtration rate (eGFR - CKD-Epidemiology Collaboration creatinine based). Multivariate analysis was performed to determine independent variables associated with mortality and major adverse cardiovascular events (MACE). Results: The independent variables, predictive of 12-month mortality in PCI patients, were: age >64 years (hazard ratio [HR] 3.10 [95% CI 1.73-5.55], p < 0.001), 3-vessel disease (HR 1.72 [95% CI 1.10-2.68], p = 0.016) and CKD stage. Compared to stage 1 CKD (eGFR >89), HR of death increased in a progressive pattern below eGFR <75: eGFR 60-74, HR 2.40 (95% CI 1.2-4.78), p = 0.013, eGFR 45-59, HR 3.27 (95% CI 1.55-6.9), p = 0.002, eGFR 30-44, HR 4.10 (95% CI 1.82-9.24), p = 0.001, eGFR <30, HR 7.97 (95% CI 3.65-17.40), p < 0.001. In patients with eGFR <75, multivariate analysis demonstrated that DES use was an independent predictor of lower MACE (HR BMS vs. DES 1.8, p = 0.0044). Conclusion: Age, severity of CKD and 3-vessel disease were independent predictors of mortality following PCI. The mortality risk in CKD patients increased progressively with eGFR <75. The use of DES was associated with a lower rate of MACE in CKD patients with eGFR <75.

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“…20,[22][23][24] Moreover, a low response to clopidogrel might be an independent predictor of the poorer outcomes in these CKD patients. Nowadays, the use of higher than usual clopidogrel doses (600 mg as loading dose and 150 mg as maintenance dose), 25 longer therapy duration (beyond 12 months), 26 or alternative more potent thienopyridine agents such as prasugrel 27,28 or ticagrelor 29 have been proposed as ways to overcome the clopidogrel resistance in CKD. However, patients with CKD also have higher bleeding tendency.…”

Section: Discussionmentioning

confidence: 99%

Effect of Estimated Glomerular Filtration Rate Decline on the Efficacy and Safety of Clopidogrel With Aspirin in Minor Stroke or Transient Ischemic Attack

Zhou¹,

Pan²,

Wu³

et al. 2016

Stroke

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C hronic kidney disease (CKD) is associated with a high prevalence of stroke, 1,2 and reduced estimated glomerular filtration rate (eGFR) can be a strong predictor of higher recurrence, comorbidity, and mortality among patients with acute ischemic stroke. [3][4][5] As the backbone of P2Y12 inhibition, 6 clopidogrel is often recommended for preventing stroke, especially in patients with noncardioembolic ischemic stroke. 7 However, specific recommendations for antiplatelet therapy in patients with ischemicBackground and Purpose-Patients with chronic kidney disease (CKD) are at a particularly high risk for ischemic and bleeding events. Limited data exist as to the efficacy and safety of clopidogrel in stroke patients with renal dysfunction. Therefore, we sought to assess the impact of decreased kidney function on clinical outcomes for stroke patients on clopidogrel-aspirin treatment. Methods-Patients in the CHANCE trial (Clopidogrel in High-Risk Patients With Acute Nondisabling CerebrovascularEvents) were randomized to clopidogrel-aspirin or aspirin-alone treatment. The primary efficacy outcome was new stroke during 90 days, whereas bleeding was the safety outcome. Patients were stratified according to estimated glomerular filtration rate. Results-Dual clopidogrel-aspirin therapy was associated with a marked reduction in new strokes compared with the therapy of aspirin alone in patients with normal renal function (hazard ratio, 0.77; 95% confidence interval, 0. CKD is characterized as a state with a prothrombotic tendency where excessive platelet activation and dysfunction plays a pivotal role. On the contrary, the risk of all-cause major hemorrhage increased in a graded fashion across all stages of CKD. 8Bleeding complications may occur in patients even with a normal coagulation profile or elevated coagulation factors.2 Therefore, assessment of the efficacy and safety of dual antiplatelet therapy with clopidogrel and aspirin for treating and preventing cerebrovascular diseases in the setting of CKD is of great significance. 2,9The CHANCE trial (Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events) was designed to determine the protection effect against stroke and bleeding risk of combination therapy of clopidogrel plus aspirin compared with aspirin alone among patients with minor stroke or transient ischemic attack (TIA).10,11 On the basis of the CHANCE trial, we aimed to investigate whether declined eGFR would be associated with altered efficacy and safety of dual antiplatelet therapy. Methods Study PopulationCHANCE was a randomized, double-blind, placebo-controlled clinical trial conducted at 114 clinical centers in China. Details about the CHANCE study design and results have been published elsewhere. [10][11][12] Within 24 hours after the onset of minor ischemic stroke or high-risk TIA, patients were randomly assigned to either clopidogrel plus aspirin (clopidogrel at an initial dose of 300 mg, followed by 75 mg per day for 90 days, plus aspirin at a dose of 75 mg per day for the fi...

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Outcomes with prolonged clopidogrel therapy after coronary stenting in patients with chronic kidney disease

Cited by 27 publications

References 34 publications

Prevalence of Chronic Kidney Disease, Thrombotic Cardiovascular Events, and Use of Oral P2Y<sub>12</sub> Inhibitors among Veterans

Prevalence of Chronic Kidney Disease, Thrombotic Cardiovascular Events, and Use of Oral P2Y<sub>12</sub> Inhibitors among Veterans

Impact of Mild-to-Moderate Chronic Kidney Disease on One Year Outcomes after Percutaneous Coronary Intervention

Effect of Estimated Glomerular Filtration Rate Decline on the Efficacy and Safety of Clopidogrel With Aspirin in Minor Stroke or Transient Ischemic Attack

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