title: Discontinuation of long-term clopidogrel therapy is associated with death and myocardial infarction after saphenous vein graft percutaneous coronary intervention.
abstract: OBJECTIVE
  This study sought to examine the pattern of death and myocardial infarction (MI) after clopidogrel cessation in patients undergoing percutaneous coronary intervention (PCI) of the saphenous vein graft (SVG).
  
  
  BACKGROUND
  The timing and incidence of adverse events by different durations of clopidogrel therapy after SVG PCI remain unknown.
  
  
  METHODS
  This is a cohort study of patients undergoing SVG PCI between 2000 and 2009, followed for all-cause mortality or MI after stopping clopidogrel. Incidence rates were calculated across different time periods after clopidogrel cessation. Adjusted incidence rate ratios (IRR) were calculated with multivariable regression (piecewise exponential and Poisson).
  
  
  RESULTS
  There were 603 patients who underwent SVG PCI, of which 411 were event-free at the time of clopidogrel cessation. The incidence rate (95% confidence interval: [CI])/1,000 person-days of death or MI after stopping clopidogrel in the time intervals of 0 to 90 days, 91 to 365 days, and 1 to 2 years were 1.26 (95% CI: 0.93 to 1.70), 0.41 (95% CI: 0.30 to 0.56), and 0.41 (95% CI: 0.30 to 0.55), respectively. In multivariable analyses, the overall IRR (95% CI) for death or MI in the 0- to 90-day interval after stopping clopidogrel compared with the 91- to 365-day interval was 2.58 (95% CI: 1.64 to 4.07). Similar results were observed over a broad range of clopidogrel treatment durations (<6 months, 6 months to 1 year, 1 to 2 years, or >2 years). The results were also consistent across subgroups, including sex, stent type, stent diameter, PCI period, and diabetes status. When death alone was evaluated, there remained a significant increase in the event rate in the 0- to 90-day interval compared with the 91- to 365-day interval (IRR: 2.33; 95% CI: 1.32 to 4.11).
  
  
  CONCLUSIONS
  A clustering of events was observed in the initial 0 to 90 days after clopidogrel cessation in all treatment durations of clopidogrel investigated after SVG PCI. These results might have important implications in high-risk cohorts undergoing PCI. Additional studies are needed to elucidate the mechanisms underlying the early clustering of events after clopidogrel cessation.
authors.affiliation: Department of Cardiology, Kaiser Permanente, Los Angeles, CA 90027, USA.
authors.forename: Amit
authors.initials: A
authors.lastname: Sachdeva
authors.forename: Sumati
authors.initials: S
authors.lastname: Bavisetty
authors.forename: Gerald
authors.initials: G
authors.lastname: Beckham
authors.forename: Albert Y-J
authors.initials: AY
authors.lastname: Shen
authors.forename: Vicken
authors.initials: V
authors.lastname: Aharonian
authors.forename: Prakash
authors.initials: P
authors.lastname: Mansukhani
authors.forename: Gregg W
authors.initials: GW
authors.lastname: Stone
authors.forename: Martin
authors.initials: M
authors.lastname: Leon
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Moses
authors.forename: Naing
authors.initials: N
authors.lastname: Moore
authors.forename: Ric
authors.initials: R
authors.lastname: Hyett
authors.forename: Richard
authors.initials: R
authors.lastname: Contreras
authors.forename: Somjot S
authors.initials: SS
authors.lastname: Brar
mesh_terms: D000368:Aged; D002140:California / Q000453:epidemiology; D002423:Cause of Death / Q000639:trends; D000077144:Clopidogrel; D004334:Drug Administration Schedule; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D009203:Myocardial Infarction / Q000401:mortality / Q000628:therapy*; D062645:Percutaneous Coronary Intervention; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage; D016079:Refusal to Treat / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012307:Risk Factors; D012501:Saphenous Vein / Q000637:transplantation*; D015996:Survival Rate / Q000639:trends; D013988:Ticlopidine / Q000008:administration & dosage / Q000031:analogs & derivatives*
chemical_list: D010975:Platelet Aggregation Inhibitors; D000077144:Clopidogrel; D013988:Ticlopidine