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Prolonging Clopidogrel after PCI

Are DM patients at risk for increased bleeding?

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Prolonging the duration of clopidogrel treatment for >12 months after percutaneous coronary revascularization (PCI) in patients with diabetes mellitus (DM) may decrease very late death or myocardial infarction (MI) in individuals with DM receiving first-generation drug-eluting stents (DES), according to a study of 28,849 patients with DM undergoing PCI. Patients were categorized into 3 groups: 1) 16,332 without DM; 2) 9,905 with DM treated with oral medications or diet; and 3) 2,612 with DM treated with insulin. Study results indicated that prolonged clopidogrel treatment was:

• Associated with a decreased risk of death (HR=0.59) and death or MI (HR=0.67) in patients with DM treated with insulin who received DES.

• Associated with less death (HR=0.61) and death or MI (HR=0.61) in patients with noninsulin-treated DM receiving DES.

• Not associated with a lower risk in patients without DM or in any group receiving bare-metal stents.

Citation: Thukkani AK, Agrawal K, Prince L, et al. Long-term outcomes in patients with diabetes mellitus related to prolonging clopidogrel more than 12 months after coronary stenting. J Am Coll Cardiol. 2015;66:1091-101. doi: 10.1016/j.jacc.2015.06.1339.

Commentary: DAPT is used after drug-eluting stent implantation in order to reduce the risk of stent thrombosis, but the optimal length of treatment is not clear. The current standard of care is to use DAPT for 6 to 12 months following drug-eluting stent implantation. A recent meta-analysis showed that extended use of DAPT is associated with 8 fewer myocardial infarctions but 6 more major bleeding events per 1,000 treated patients per year compared to shorter duration DAPT1. That study also showed that extended duration DAPT may have either no effect or even an adverse effect with regard to mortality. The article suggested that there is no compelling evidence to use DAPT for greater than 12 months in most patients, but left room for individualized decision making. The current study suggests that a sub-group of patients who may benefit from extended DAPT are patients with diabetes. —Neil Skolnik, MD

1. Spencer FA, Prasad M, Vandvik PO, Chetan D, Zhou Q, Guyatt G. Longer versus shorter duration dual-antiplatelet therapy after drug-eluting stent placement: a systematic review and meta-analysis. Ann Intern Med. 2015; 163(2):118-126. doi:10.7326/M15-0083.

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