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Interesting study showing that after conclusion of plavix therapy for DES and BMS for the 6 weeks and 1 year as recommended, the risk for stent clotting maybe actually higher. What does this mean for anesthesiologists?
http://jama.ama-assn.org/cgi/reprint/299/5/532
Study Highlights
http://jama.ama-assn.org/cgi/reprint/299/5/532
Study Highlights
- All patients discharged from the VA hospital with a diagnosis of acute myocardial infarction or unstable angina between 2003 and 2005 were eligible for study analysis. These diagnoses were culled from patient records and were made with use of standard diagnostic criteria for ACS. Patients who had had an adverse event related to clopidogrel therapy were not included in the study.
- Clopidogrel use was measured with use of VA pharmacy records.
- The primary study outcome was the relationship between use of clopidogrel and the combined endpoint of hospitalization for acute myocardial infarction and all-cause mortality. Researchers examined 90-day periods after discontinuation of clopidogrel for this outcome.
- 3137 patients provided data for analysis. The mean age was 66 years, and 98.2% were men.
- Among medically treated patients, the mean duration of clopidogrel therapy was 302 days. 34.8% of subjects took clopidogrel for more than 12 months. The mean duration of clopidogrel therapy among patients treated with PCI was 278 days.
- The median follow-up period after discontinuation of clopidogrel was 196 days among medically treated subjects and 203 days among subjects treated with PCI. During this period, the combined outcome of all-cause mortality or acute myocardial infarction occurred in 17.1% of medically treated subjects and 7.9% of patients who received PCI.
- Among medically treated patients, 60.8% of study events occurred between 0 and 90 days after discontinuation of clopidogrel, whereas 21.3% and 9.7% of events occurred between 91 and 180 days and 181 and 270 days after cessation of clopidogrel, respectively. The respective rates of study events among patients treated with PCI were 58.9%, 23.4%, and 6.5% for clopidogrel cessation at 0 to 90 days, 91 to 180 days, and 181 to 270 days.
- Compared with the period of 91 to 180 days after cessation of clopidogrel, the period of 0 to 90 days after discontinuation of clopidogrel increased the risk for study events by 1.98 on multivariable analysis of medically treated patients. The respective incident risk ratio among PCI-treated patients was 1.82. The increased risk associated with earlier cessation of clopidogrel was also significant for the outcome of acute myocardial infarction alone.
- The risk for early cessation of clopidogrel persisted regardless of the duration since the original ACS event.
- 20.8% of subjects had 1 or more diagnostic codes entered for bleeding during follow-up. When these patients were excluded from analysis, the risk for early cessation of clopidogrel for the primary outcome remained significant.
- Current recommendations call for clopidogrel treatment for at least 1 month after ACS for patients treated with medications or bare metal stents and for at least 1 year for patients treated with placement of drug-eluting stents.
- In the current study, cessation of clopidogrel during a 0- to 90 day interval after ACS increased the risk for the combined outcome of mortality and acute myocardial infarction, regardless of whether patients received PCI or medical therapy only.
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