Abstract
Clopidogrel is recommended with aspirin for up to one year after coronary drug-eluting stent (DES) placement but the value beyond this time is controversial. Patients with diabetes mellitus (DM) are at higher risk of cardiovascular events than patients without DM, and may benefit from more prolonged clopidogrel treatment. Methods: We assessed all DM patients in the National VA Healthcare System who received a coronary stent from 2002- 2006. Baseline factors and comorbities, pharmacy data, and adverse events during follow-up were collected. We estimated crude and adjusted hazard ratios for prolonged versus 12 or less months of clopidogrel on the risk of death, and death or myocardial infarction (MI), stroke, major bleeding, and repeat revascularization up to 4 years after stenting using Cox proportional hazards. We used a landmark analysis that excluded all events up to 12 months after stenting with DES or bare-metal stents (BMS). Results: Of 42,254 patients who received a coronary stent, 13,657 had diabetes on treatment. 2,808 received a DES and 2,782 a BMS. 39% of DES pts and 23% of BMS pts were on clopidogrel >12months. The results of the landmark analysis showed no differences for stroke, major bleeding or repeat revascularization in either group. Conclusion: In this large unrestricted veteran population, prolonged clopidogrel use of more than 12 months in patients with diabetes receiving coronary stenting associated with lower risk of death and death and MI particularly after DES. These data suggest that prolonged use more than one year may be of benefit in DM patients receiving a DES. Figure: Risk of Outcomes After the 12 Month Landmark for Prolonged vs 12 or Less Months Clopidogrel Use † Adjusted for age, diabetes, ACS during index admission, hypertension, PVD, heart failure, warfarin within 7-days of index discharge, year of stent, occurrence of another outcome within 12-months of index procedure
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