Abstract P382: Continued Thienopyridine Use at Six Months After PCI is Not Associated with Better Outcomes in End-Stage Renal Disease Requiring Dialysis

Abstract

Introduction: While coronary disease is common in end-stage renal disease, there are few studies of thienopyridine use after PCI in this population. Guidelines recommend 1 to 12 months of thienopyridine use depending on stent type, but are based on patients without advanced kidney disease. However, patients on dialysis often have more severe coronary disease and higher risks of bleeding. We hypothesized that in patients on dialysis undergoing PCI with stenting: 1) most will discontinue thienopyridines prior to 1 year; 2) discontinuation of thienopyridines prior to 6 months post-PCI will associate with higher risks of death or MI, but a lower risk of bleeding. Methods: Using the US Renal Data System, we identified patients on dialysis with Medicare Parts A+B+D (with low-income subsidy) who had PCI with stenting between 7/07 and 12/09. Thienopyridine discontinuation was defined as >30-day gap in supply. We performed a landmark analysis, selecting patients who were event-free at 6 months after PCI, and categorized them as having discontinued thienopyridines or not at that point. We propensity-matched patients for discontinued vs. continued use and fit Cox models to examine death, death or MI, and hospitalized bleeding. Results: We identified 4686 patients, 66% of whom received a drug-eluting stent [DES]. At 90-days, 78% of DES and 65% of bare metal stent (BMS) patients used a thienopyridine; this proportion fell to 64% and 48% at 6 months, and 42% and 29% at 1 year. Overall rates of death and MI were high (Table). In the matched cohorts, patients who discontinued thienopyridine use prior to 6 months (vs. continued use) had no significant differences in long-term outcomes (Table). Conclusions: In patients on dialysis who undergo PCI with stenting, most use thienopyridines for <1 year. Continued thienopyridine use at 6 months was not associated with a significant benefit or with higher bleeding risk. Our study highlights the need for future trials to determine the optimal duration of thienopyridine use after PCI in this high-risk population.