title: Thienopyridine use after coronary stenting in low income patients enrolled in medicare part D receiving maintenance dialysis.
abstract: BACKGROUND
  Coronary stenting in patients on dialysis has increased by nearly 50% over the past decade, despite heightened risks of associated stent thrombosis and bleeding relative to the general population. We examined clopidogrel, prasugrel or ticlopidine use after percutaneous coronary intervention (PCI) with stenting in patients on dialysis. We conducted 3-, 6-, and 12-month landmark analyses to test the hypothesis that thienopyridine discontinuation prior to those time points would be associated with higher risks of death, myocardial infarction, or repeat revascularization, and a lower risk of major bleeding episodes compared with continued thienopyridine use.
  
  
  RESULTS
  Using the US Renal Data System, we identified 8458 patients on dialysis with Medicare Parts A+B+D undergoing PCI with stenting between July 2007 and December 2010. Ninety-nine percent of all thienopyridine prescriptions were for clopidogrel. At 3 months, 82% of patients who received drug-eluting stents (DES) had evidence of thienopyridine use. These proportions fell to 62% and 40% at 6 and 12 months, respectively. In patients who received a bare-metal stent (BMS), 70%, 34%, and 26% of patients had evidence of thienopyridine use at 3, 6, and 12 months, respectively. In patients who received a DES, there was a suggestion of higher risks of death or myocardial infarction associated with thienopyridine discontinuation in the 3-, 6-, and 12-months landmark analyses, but no higher risk of major bleeding episodes. In patients who received a BMS, there were no differences in death or cardiovascular events, and possibly lower risk of major bleeding with thienopyridine discontinuation in the 3- and 6-month landmark analyses.
  
  
  CONCLUSIONS
  The majority of patients on dialysis who undergo PCI discontinue thienopyridines before 1 year regardless of stent type. While not definitive, these data suggest that longer-term thienopyridine use may be of benefit to patients on dialysis who undergo PCI with DES.
authors.affiliation: Division of Nephrology, Stanford University School of Medicine, Stanford, CA (T.I.C., M.E.M.R., G.M.C., W.C.W.).
authors.forename: Tara I
authors.initials: TI
authors.lastname: Chang
authors.affiliation: Division of Nephrology, Stanford University School of Medicine, Stanford, CA (T.I.C., M.E.M.R., G.M.C., W.C.W.).
authors.forename: Maria E
authors.initials: ME
authors.lastname: Montez-Rath
authors.affiliation: Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, CA (J.I.S.).
authors.forename: Jenny I
authors.initials: JI
authors.lastname: Shen
authors.affiliation: Division of Research, Kaiser Permanente Northern California, Oakland, CA (M.D.S.).
authors.forename: Matthew D
authors.initials: MD
authors.lastname: Solomon
authors.affiliation: Division of Nephrology, Stanford University School of Medicine, Stanford, CA (T.I.C., M.E.M.R., G.M.C., W.C.W.).
authors.forename: Glenn M
authors.initials: GM
authors.lastname: Chertow
authors.affiliation: Division of Nephrology, Stanford University School of Medicine, Stanford, CA (T.I.C., M.E.M.R., G.M.C., W.C.W.) Section of Nephrology, Baylor College of Medicine, Houston, TX 77030-3411 (W.C.W.).
authors.forename: Wolfgang C
authors.initials: WC
authors.lastname: Winkelmayer
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000379:methods*; D015331:Cohort Studies; D016001:Confidence Intervals; D023903:Coronary Restenosis / Q000517:prevention & control; D023921:Coronary Stenosis / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D016208:Databases, Factual; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007676:Kidney Failure, Chronic / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D008297:Male; D054524:Medicare Part D / Q000191:economics*; D008875:Middle Aged; D011203:Poverty; D016016:Proportional Hazards Models; D011725:Pyridines / Q000627:therapeutic use*; D011859:Radiography; D012189:Retrospective Studies; D018570:Risk Assessment; D015607:Stents; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States
chemical_list: D011725:Pyridines; C446540:thienopyridine
keywords: clopidogrel; end‐stage renal disease; epidemiology; percutaneous coronary intervention; revascularization