Long-Term Outcomes in Patients With Diabetes Mellitus Related to Prolonging Clopidogrel More Than 12 Months After Coronary Stenting

Thukkani, Arun K.; Agrawal, Kush; Prince, Lillian; Smoot, Kyle J.; Dufour, Alyssa B.; Cho, Kelly; Gagnon, David; Sokolovskaya, Galina; Ly, Sophia; Temiyasathit, Sara; Faxon, David P.; Gaziano, J. Michael; Kinlay, Scott

doi:10.1016/j.jacc.2015.06.1339

Cited by 32 publications

(27 citation statements)

References 25 publications

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“…21 This study, however, like other retrospective studies, has relevant limitations, and appropriate adjustment is unlikely to eliminate selection bias. 22 Randomised studies comparing different DAPT regimens have provided results of subgroup analyses.…”

Section: Diabetes Mellitus and Daptmentioning

confidence: 88%

Short term versus long term dual antiplatelet therapy after implantation of drug eluting stent in patients with or without diabetes: systematic review and meta-analysis of individual participant data from randomised trials

Gargiulo

Windecker

Costa

et al. 2016

BMJ

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Objective To compare clinical outcomes between short term (up to 6 months) and long term (12 months) dual antiplatelet therapy (DAPT) after placement of a drug eluting stent in patients with and without diabetes.Design Individual participant data meta-analysis. Cox proportional regression models stratified by trial were used to assess the impact of diabetes on outcomes.Data source Medline, Embase, and Cochrane databases and proceedings of international meetings searched for randomised controlled trials comparing durations of DAPT after placement of a drug eluting stent. Individual patient data pooled from six DAPT trials.Primary outcome Primary study outcome was one year risk of major adverse cardiac events (MACE), defined as cardiac death, myocardial infarction, or definite/probable stent thrombosis. All analyses were conducted by intention to treat.Results Six trials including 11 473 randomised patients were pooled. Of these patients, 3681 (32.1%) had diabetes and 7708 (67.2%) did not (mean age 63.7 (SD 9.9) and 62.8 (SD 10.1), respectively), and in 84 (0.7%) the information was missing. Diabetes was an independent predictor of MACE (hazard ratio 2.30, 95% confidence interval 1.01 to 5.27; P=0.048 At one year follow-up, long term DAPT was not associated with a decreased risk of MACE compared with short term DAPT in patients with (1.05, 0.62 to 1.76; P=0.86) or without (0.97, 0.67 to 1.39; P=0.85) diabetes (P=0.33 for interaction). The risk of myocardial infarction did not differ between the two DAPT regimens (0.95, 0.58 to 1.54; P=0.82; for those with diabetes and 1.15, 0.68 to 1.94; P=0.60; for those without diabetes (P=0.84 for interaction). There was a lower risk of definite/probable stent thrombosis with long term DAPT among patients with (0.26, 0.09 to 0.80; P=0.02) than without (1.42, 0.68 to 2.98; P=0.35) diabetes, with positive interaction testing (P=0.04 for interaction), although the landmark analysis showed a trend towards benefit in both groups. Long term DAPT was associated with higher rates of major or minor bleeding, irrespective of diabetes (P=0.37 for interaction).Conclusions Although the presence of diabetes emerged as an independent predictor of MACE after implantation of a drug eluting stent, compared with short term DAPT, long term DAPT did not reduce the risk of MACE but increased the risk of bleeding among patients with stents with and without diabetes.

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Section: Diabetes Mellitus and Daptmentioning

confidence: 88%

Short term versus long term dual antiplatelet therapy after implantation of drug eluting stent in patients with or without diabetes: systematic review and meta-analysis of individual participant data from randomised trials

Gargiulo

Windecker

Costa

et al. 2016

BMJ

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“…In a study of 28 849 Veterans Affairs patients who received a drug-eluting stent, the 1-year event rate for MI was 7.6% for diabetic patients requiring insulin, 5.4% in diabetic patients not requiring insulin, and 4.4% in nondiabetic patients. 63 The need for revascularization over the first year of follow-up was 17.3%, 14.8%, and 11.7% respectively. In 2 recent trials of everolimus-eluting stents, the outcomes of death, MI, and stroke were significantly higher in the patients with diabetes mellitus compared with those without diabetes mellitus.…”

Section: Circulation Researchmentioning

confidence: 92%

Vascular Complications of Diabetes

Beckman

Creager

2016

Circulation Research

299

218

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Over the last several decades, the global incidence and prevalence of diabetes mellitus has increased significantly. The raised incidence rate is projected to continue as greater numbers of persons adopt a Western lifestyle and diet. Patients with diabetes mellitus are at heightened risk of both adverse microvascular and cardiovascular events. Moreover, once cardiovascular disease develops, diabetes mellitus exacerbates progression and worsens outcomes. The medical management of patients with diabetes mellitus mandates comprehensive risk factor modification and antiplatelet therapy. Recent clinical trials of new medical therapies continue to inform the care of patients with diabetes mellitus to reduce both cardiovascular morbidity and mortality.

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“…The observational studies also indicate that patients with DM who received prolonged DAPT had a lower risk of death or MI. [1718]…”

Section: Discussionmentioning

confidence: 99%

Shorter- versus Longer-duration Dual Antiplatelet Therapy in Patients with Diabetes Mellitus Undergoing Drug-eluting Stents Implantation

Huang

Wang

Chen

et al. 2016

Chinese Medical Journal

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Background:Patients with diabetes mellitus (DM) have a higher risk of thromboembolic events; however, the optimal duration of dual antiplatelet therapy (DAPT) remains unclear. The goal of this study was to assess the efficacy and safety of various DAPT durations in patients with DM undergoing drug-eluting stent implantation.Methods:We conducted a literature search for randomized controlled trials (RCTs). We searched databases including EMBASE, PubMed, Cochrane Library, and Scopus up to June 2016. Investigators extracted data independently, including outcomes, characteristics, and study quality. A random-effect model was used to pool odds ratios (ORs) with 95% confidence intervals (CIs) of the clinical outcomes.Results:Six RCTs totaling 6040 patients with DM were included in the study. Shorter-duration DAPT resulted in an increased rate of stent thrombosis (ST) (OR, 1.83, 95% CI: 1.03–3.26, P = 0.04), but did not increase the risk of myocardial infarction (OR, 1.33, 95% CI: 0.71–2.47, P = 0.37), stroke (OR, 0.96, 95% CI: 0.52–1.77, P = 0.90), target vessel revascularization (OR, 1.19, 95% CI: 0.46–3.07, P = 0.71), all-cause death (OR: 0.72, 95% CI: 0.48–1.09, P = 0.12), or cardiac death (OR, 0.82, 95% CI: 0.49–1.36, P = 0.44) significantly. Shorter-duration DAPT was associated with a decreased risk of major bleeding (OR, 0.60, 95% CI: 0.38–0.94, P = 0.02).Conclusion:In patients with DM, longer-duration DAPT had a lower risk of ST, but was associated with an increased bleeding risk.

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Long-Term Outcomes in Patients With Diabetes Mellitus Related to Prolonging Clopidogrel More Than 12 Months After Coronary Stenting

Abstract: Extending the duration of clopidogrel treatment >12 months may decrease very late death or MI only in patients with DM receiving first-generation DES. Future studies should address this question in patients receiving second-generation DES.

Cited by 32 publications

References 25 publications

Short term versus long term dual antiplatelet therapy after implantation of drug eluting stent in patients with or without diabetes: systematic review and meta-analysis of individual participant data from randomised trials

Short term versus long term dual antiplatelet therapy after implantation of drug eluting stent in patients with or without diabetes: systematic review and meta-analysis of individual participant data from randomised trials

Vascular Complications of Diabetes

Shorter- versus Longer-duration Dual Antiplatelet Therapy in Patients with Diabetes Mellitus Undergoing Drug-eluting Stents Implantation

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