title: Outcomes with prolonged clopidogrel therapy after coronary stenting in patients with chronic kidney disease.
abstract: OBJECTIVE
  Patients with chronic kidney disease (CKD) are at high risk of death or myocardial infarction (MI) after percutaneous coronary interventions (PCI). We assessed whether prolonged dual antiplatelet therapy beyond the recommended 12 months may prevent adverse outcomes in patients with CKD receiving drug-eluting stents (DES) or bare-metal stents (BMS).
  
  
  METHODS
  We studied all Veterans receiving PCI with BMS or first-generation DES in the Veterans Affairs (VA) Healthcare System between 2002 and 2006, classified by CKD (estimated glomerular filtration rate <60 mL/min) or normal renal function. We used landmark analyses from 12 months after PCI with Cox proportional hazards multivariable and propensity-adjusted models to assess the effect of prolonged clopidogrel (more than 12  months) versus 12 months or less after PCI on clinical outcomes from 1 year to 4 years after PCI.
  
  
  RESULTS
  Of 23 042 eligible subjects receiving PCI, 4880 (21%) had CKD. Compared with normal renal function, patients with CKD had higher risks of death or MI 1-4 years after DES (21% vs 12%, HR=1.75; 95% CI 1.51 to 2.04) or BMS (28% vs 15%, HR=2.10; 95% CI 1.90 to 2.32). In patients with CKD receiving DES, clopidogrel use of more than 12 months after PCI was associated with lower risks of death or MI (18% vs 24%, HR=0.74; 95% CI 0.58 to 0.95), and death (15% vs 23%, HR=0.61; 95% CI 0.47 to 0.80), but had no effect on repeat revascularisation 1-4 years after PCI.
  
  
  CONCLUSIONS
  In patients with CKD, prolonging clopidogrel beyond 12 months after PCI may decrease the risk of death or MI only in patients receiving first-generation DES. These results support a patient-tailored approach to prolonging clopidogrel after PCI.
authors.affiliation: Cardiovascular Division, Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts, USA Cardiovascular Division, Boston Medical Center, Boston, Massachusetts, USA.
authors.forename: Omar K
authors.initials: OK
authors.lastname: Siddiqi
authors.affiliation: Cardiovascular Division, Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts, USA MAVERIC, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA.
authors.forename: Kyle J
authors.initials: KJ
authors.lastname: Smoot
authors.affiliation: Cardiovascular Division, Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts, USA MAVERIC, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA Harvard Medical School, Boston, Massachusetts, USA Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA.
authors.forename: Alyssa B
authors.initials: AB
authors.lastname: Dufour
authors.affiliation: Cardiovascular Division, Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts, USA MAVERIC, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Kelly
authors.initials: K
authors.lastname: Cho
authors.affiliation: Cardiovascular Division, Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts, USA MAVERIC, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA.
authors.forename: Melissa
authors.initials: M
authors.lastname: Young
authors.affiliation: Cardiovascular Division, Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts, USA MAVERIC, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA Boston University School of Public Health, Boston, Massachusetts, USA.
authors.forename: David R
authors.initials: DR
authors.lastname: Gagnon
authors.affiliation: Cardiovascular Division, Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts, USA.
authors.forename: Samantha
authors.initials: S
authors.lastname: Ly
authors.affiliation: Cardiovascular Division, Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts, USA.
authors.forename: Sara
authors.initials: S
authors.lastname: Temiyasathit
authors.affiliation: Cardiovascular Division, Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts, USA Harvard Medical School, Boston, Massachusetts, USA Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA.
authors.forename: David P
authors.initials: DP
authors.lastname: Faxon
authors.affiliation: Cardiovascular Division, Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts, USA MAVERIC, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA Harvard Medical School, Boston, Massachusetts, USA Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA.
authors.forename: J Michael
authors.initials: JM
authors.lastname: Gaziano
authors.affiliation: Cardiovascular Division, Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts, USA Harvard Medical School, Boston, Massachusetts, USA Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA.
authors.forename: Scott
authors.initials: S
authors.lastname: Kinlay
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000077144:Clopidogrel; D003324:Coronary Artery Disease / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D004334:Drug Administration Schedule; D054855:Drug-Eluting Stents; D005260:Female; D005919:Glomerular Filtration Rate; D006801:Humans; D007668:Kidney / Q000503:physiopathology; D008297:Male; D008670:Metals; D008875:Middle Aged; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000209:etiology; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage* / Q000009:adverse effects; D057216:Propensity Score; D016016:Proportional Hazards Models; D011474:Prosthesis Design; D051436:Renal Insufficiency, Chronic / Q000150:complications* / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D013988:Ticlopidine / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives*; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D014493:United States Department of Veterans Affairs
chemical_list: D008670:Metals; D010975:Platelet Aggregation Inhibitors; D000077144:Clopidogrel; D013988:Ticlopidine