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The Value of Long-Term Clopidogrel After Stenting

The clinical value was significant for drug-eluting stent recipients, but not for bare-metal stent recipients, in an observational study.

The risk for stent thrombosis associated with clopidogrel discontinuation is greater after drug-eluting stent (DES) implantation than after bare-metal stent (BMS) implantation, according to a recent observational study (J Am Coll Cardiol 2006; 48:[e-pub before print]; see http://dx.doi.org/10.1016/j.jacc.2006.10.026). In a new observational study, researchers retrospectively assessed clopidogrel use and long-term clinical outcomes in 3609 consecutive patients who received intracoronary stents (34% drug-eluting) at Duke Heart Center and who were event-free at 6 months. Rates of self-reported clopidogrel use were 52% among DES recipients and 17% among BMS recipients at 6-month follow-up, and continued to decline thereafter.

Among DES recipients, the multivariable-adjusted risk for death at 24 months was significantly lower in patients using clopidogrel at 6 months than in those not using it at 6 months (2.0% vs. 5.3%), as was the combined risk for death or MI (3.1% vs. 7.2%). The gap in 24-month event rates between clopidogrel users and nonusers was even greater based on self-reported use at 12 months among patients who were event-free at 12 months: death (0.0% vs. 3.5%) and death or MI (0.0% vs. 4.5%). Among BMS recipients, there were no significant gaps in event rates related to clopidogrel use. Notably, event rates were lower among DES recipients who used clopidogrel than among BMS recipients, regardless of their clopidogrel use.

Comment: Two major findings emerged from this observational study: 1) The patients who fared best after stent implantation were those who received drug-eluting stents and long-term clopidogrel therapy; and 2) long-term clopidogrel therapy after bare-metal stent implantation had no evidence of benefit after 6 months. An important caveat is that the long-term nonfatal risks of clopidogrel use (e.g., bleeding) were not assessed. Nevertheless, if prospective, randomized studies confirm these findings, they would suggest the need for clopidogrel for at least 24 months after DES implantation and the appropriateness of BMS for patients who cannot receive long-term clopidogrel therapy.

— Howard C. Herrmann, MD

Published in Journal Watch Cardiology December 5, 2006

Citation(s):

Eisenstein EL et al. Clopidogrel use and long-term clinical outcomes after drug-eluting stent implantation. JAMA 2007 Jan 10; 297:[e-pub before print]. (http://jama.ama-assn.org/cgi/content/full/297.2.joc60179v1)