Impact of chronic kidney disease on 2‐year clinical outcomes in patients treated with 6‐month or 24‐month DAPT duration: An analysis from the PRODIGY trial

Gargiulo, Giuseppe; Santucci, Andrea; Piccolo, Raffaele; Franzone, Anna; Ariotti, Sara; Baldo, Andrea; Esposito, Giovanni; Moschovitis, Aris; Windecker, Stephan; Valgimigli, Marco

doi:10.1002/ccd.26921

Cited by 24 publications

(18 citation statements)

References 30 publications

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“…In contrast, in a study of previously revascularized patients with CAD, CKD defined as GFR<60 was associated with an adjusted HR for stroke of 2.3 (95% CI 1.2-4.7) 48 and our results could be explained by the limited power to detect differences between the groups. But it could also indicate that RD is not a strong risk factor for stroke in the present population, which is also a finding supported in a recent substudy of PROlonging Dual Antiplatelet Treatment After Grading stent-induced Intimal hyperplasia study (PRODIGY) where no difference in the risk of stroke or transient ischemic attack was observed between those with and without RD at 2-years of follow-up (HR 1.97, 95% CI (0.79-4.92) 136 .…”

Section: Influence Of Rd On Cvd Outcomes In Patients With Stable Cadsupporting

confidence: 87%

SWEDEHEART-1-year data show no benefit of newer generation drug-eluting stents over bare-metal stents in patients with severe kidney dysfunction following percutaneous coronary intervention

Edfors

James

Szummer

et al. 2020

Coronary Artery Disease

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Bakgrund Ungefär en tredjedel av alla patienter med akut hjärtinfarkt har njursvikt, vilket innebär en markant ökad risk för såväl komplikationer som nya hjärthändelser. Syftet med detta avhandlingsarbete var att undersöka vilken betydelse olika grader av njursvikt har för överlevnad och kliniska utfall, att utvärdera utfallen efter olika medicinska-och interventionella behandlingar och hur de skiljer sig åt hos patienter med njursvikt samt att utifrån blodprovsanalyser studera olika biomarkörers koppling till njursvikt och kardiovaskulära händelser. Metoder och resultat Studie I: Data från det svenska hjärtsjukvårdsregistret SWEDEHEART användes för att undersöka hur olika grader av njursvikt påverkar risken för död och kliniska utfall efter en kranskärlsröntgen p.g.a. stabil kranskärlssjukdom. Resultaten påvisade att trots justering för flertalet kliniska bakgrundsfaktorer, samsjuklighet, grad av ischemi och olika revaskulariseringmetoder, hade patienter med njursvikt en signifikant ökad risk för död, återinsjuknande i akut hjärtinfarkt och hjärtsvikt. Studie II: Registerstudie där alla patienter med hjärtinfarkt som registrerats i SWEDEHEART och som erhållit blodförtunnande behandling med antingen clopidogrel eller ticagrelor studerades. Samkörning av flera register utfördes. Jämfört med clopidogrel, var behandling med ticagrelor förknippat med lägre risk för död, återinläggning med hjärtinfarkt och stroke, dock på bekostnad av en ökad blödningsrisk, hos både njurfriska och patienter med måttlig njursvikt. Bland patienter med uttalad njursvikt observerades inte någon säker nytta, men däremot ökade risker för blödning. Studie III: Alla patienter i SWEDEHEART som genomgått kranskärlsröntgen och erhållit en kranskärlsstent (läkemedelsbärande stent (n-DES) eller stent av metall (BMS)) inkluderades i denna studie, där risken för förnyad förträngning (restenos) och akut ocklusion (stenttrombos) i stenten studerades utifrån njurfunktion. I jämförelse med BMS, innebar stentinläggning med n-DES en lägre 1-årsrisk för både restenos och stenttrombos hos patienter med lätt eller måttlig njursvikt, medan ingen skillnad noterades hos patienter med uttalad njursvikt. Studie IV: SWEDEHEART användes för både provinsamling och prospektiv långtidsuppföljning hos 1,098 patienter som vårdats med akut hjärtinfarkt. Blodprover sparades i SWEDEHEARTbiobank och 175 olika biomarkörers uttryck analyserades hypotesfritt angående kopplingar till njursvikt och kliniska utfall, som registrerades i befolknings-och patientregistret. Resultaten påvisade att flertalet av de sex stycken biomarkörer som var starkast relaterade till njursvikt också var starkt relaterade till risken för att drabbas av död, hjärtinfarkt och hjärtsvikt. Slutsats Njursvikt är en stark och oberoende riskmarkör för överdödlighet och kardiovaskulära utfall hos patienter med kranskärlssjukdom. Andra okända faktorer än de vi kunnat justera för (riskfaktorer, samsjuklighet, CAD, behandlingar) har betydelse för den försämrade prognos hos patienter med kranskärlssjukdom och nj...

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Section: Influence Of Rd On Cvd Outcomes In Patients With Stable Cadsupporting

confidence: 87%

SWEDEHEART-1-year data show no benefit of newer generation drug-eluting stents over bare-metal stents in patients with severe kidney dysfunction following percutaneous coronary intervention

Edfors

James

Szummer

et al. 2020

Coronary Artery Disease

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“…In a recent publication from the SWEDEHEART registry, Carrero et al demonstrated that prolonged, as compared to 3 months DAPT, was associated with lower risk of death, stroke, or reinfarction, regardless of underlying CKD . On the contrary, Valgimigli et al in a post‐hoc analysis of the PRODIGY trial, showed that prolonged DAPT did not reduce major adverse cardiovascular events, but this finding was again consistent between CKD and non‐CKD patients. While optimization of DAPT duration to harmonize thrombotic and bleeding risk in CKD patients is still a matter of controversy, the present meta‐analysis support, in indicated CKD PCI candidates, systematic use of newer generation DES.…”

Section: Discussionmentioning

confidence: 97%

“…Chronic kidney disease (CKD) is a prevalent risk factor for cardiovascular disease (CVD). Of note, CKD patients are more likely to die from CVD complications than to develop end‐stage kidney failure . In addition, CKD patients have increased risk of stent‐related complications when treated with percutaneous coronary interventions (PCI) such as stent thrombosis (ST) and target lesion/vessel revascularization (TLR/TVR).…”

Section: Introductionmentioning

confidence: 99%

Drug eluting stents are superior to bare metal stents to reduce clinical outcome and stent‐related complications in CKD patients, a systematic review, meta‐analysis and network meta‐analysis

Crimi

Gritti

Galiffa

et al. 2017

J Interven Cardiology

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Aims To compare clinical outcome in Chronic kidney disease (CKD) patients receiving coronary stents according to stent type BMS versus DES and 1st generation versus 2nd generation DES. Methods and Results PubMed, Cinhal, Cochrane, Embase, and Web of Science were searched for studies including CKD patients. CKD was defined as eGFR < 60 mL/min. We selected n = 35 articles leading to 376 169 patients, of which 76 557 CKD patients receiving BMS n = 35,807, 1st generation DES n = 37,650, or 2nd generation DES n = 3100. Patient receiving DES, compared to BMS, had a 18% lower all-cause mortality (RR 0.82, 95%CI 0.71-0.94). The composite of death or myocardial infarction (MI) was lower in DES patients (RR 0.78, 95%CI 0.67-0.91), as was stent thrombosis (ST) (RR 0.57, 95%CI 0.34-0.95), target vessel/lesion revascularization (TVR/TLR) (RR 0.69, 95%CI 0.57-0.84) and death for cardiovascular cause (RR 0.43, 95%CI 0.25-0.74). We also found a gradient between 1st and 2nd generation DES, through BMS. Second, compared to 1st generation DES, were associated with further relative risk (RR) reduction of -18% in of all-cause death, and lower incidence of stent-related clinical events: -39% RR of ST risk; -27 RR of TVR/TLR risk. Conclusions DES in CKD patients undergoing PCI were superior to BMS in reducing major adverse clinical events. This was possibly explained, by a lower risk of stent-related events as ST and TVR or TLR. Second, compared to 1st generation DES may furtherly reduce clinical events.

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“…Post hoc analyses of the Clopidogrel for the Reduction of Events During Observation (CREDO) and Prolonging Dual Antiplatelet Treatment After Grading Stent-Induced Intimal Hyperplasia Study (PRODIGY) trials performed in subjects with estimated glomerular filtration rate <60 mL/min/1.73 m 2 demonstrated that ≥1 year of DAPT did not affect the incidence of MACE [ 15 , 17 ]. However, DAPT for 1 year was compared with 1 month in the CREDO trial, which is not compatible with current guidelines.…”

Section: Discussionmentioning

confidence: 99%

Clinical outcomes of prolonged dual antiplatelet therapy after coronary drug-eluting stent implantation in dialysis patients

Park

Kim

et al. 2020

Clinical Kidney Journal

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Background End-stage renal disease yields susceptibility to both ischemia and bleeding. The optimal duration of dual antiplatelet therapy (DAPT) after drug-eluting stent (DES) implantation is not established in dialysis patients, who are usually excluded from randomized studies. Since recent studies implied the benefits of prolonged DAPT >12 months in chronic kidney disease, we investigated the effectiveness and safety of prolonged DAPT in dialysis patients with higher cardiovascular risks. Methods In this nationwide population-based study, we analyzed dialysis patients who underwent DES implantation from 2008 to 2015. Continued DAPT was compared with discontinued DAPT using landmark analyses, including free-of-event participants at 12 (n = 2246), 15 (n = 1925) and 18 months (n = 1692) after DES implantation. The primary outcome was major adverse cardiovascular events (MACEs): a composite of mortality, nonfatal myocardial infarction, coronary revascularization and stroke. Major bleeding was a safety outcome. Inverse probability of treatment weighting Cox regression was performed. Results Mean follow-up periods were 278.3–292.4 days, depending on landmarks. Overall, incidences of major bleeding were far lower than those of MACE. Continued DAPT groups showed lower incidences of MACE and higher incidences of major bleeding, compared with discontinued DAPT groups. In Cox analyses, continued DAPT reduced the hazards of MACE at the 12- [hazard ratio (HR) = 0.74, 95% confidence interval (CI) 0.61–0.90; P = 0.003], 15- (HR = 0.78, 95% CI 0.64–0.96; P = 0.019) and 18-month landmarks (HR = 0.79, 95% CI 0.63–0.99; P = 0.041), but without a significant increase in major bleeding at 12 (HR = 1.39, 95% CI 0.90–2.16; P = 0.14), 15 (HR = 1.13, 95% CI 0.75–1.70; P = 0.55) or 18 months (HR = 1.27, 95% CI 0.83–1.95; P = 0.27). Conclusions Prolonged DAPT reduced MACE without significantly increasing major bleeding in patients who were event-free at 12 months after DES implantation. In deciding on DAPT duration, prolonged DAPT should be considered in dialysis patients.

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Impact of chronic kidney disease on 2‐year clinical outcomes in patients treated with 6‐month or 24‐month DAPT duration: An analysis from the PRODIGY trial

Cited by 24 publications

References 30 publications

SWEDEHEART-1-year data show no benefit of newer generation drug-eluting stents over bare-metal stents in patients with severe kidney dysfunction following percutaneous coronary intervention

SWEDEHEART-1-year data show no benefit of newer generation drug-eluting stents over bare-metal stents in patients with severe kidney dysfunction following percutaneous coronary intervention

Drug eluting stents are superior to bare metal stents to reduce clinical outcome and stent‐related complications in CKD patients, a systematic review, meta‐analysis and network meta‐analysis

Clinical outcomes of prolonged dual antiplatelet therapy after coronary drug-eluting stent implantation in dialysis patients

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