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Clopidogrel Use and Mortality in Veterans with Chronic Kidney Disease and Acute Coronary

Fischer M, Ho M, McDermott K, Lowy E, Parikh C. Clopidogrel Use and Mortality in Veterans with Chronic Kidney Disease and Acute Coronary. Poster session presented at: National Kidney Foundation Clinical Spring Meeting; 2011 Apr 27; Las Vegas, NV.

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Abstract:

Chronic kidney disease (CKD) affects up to 50% of patients with acute coronary syndrome (ACS) and is associated with worse health outcomes. While clopidogrel in addition to aspirin is effective in reducing recurrent events in patients with ACS, less is known about the benefits of dual antiplatelet therapy in patients with CKD. We identified all Veterans hospitalized at VA facilities with ACS and at least one outpatient serum creatinine in the Cardiac Care Follow-up Clinical Study between 10/1/2005 - 10/1/2009. Estimated glomerular filtration rate (eGFR) was calculated using the CKD-EPI equation. CKD was defined as an eGFR < 60 ml/min/m2. Logistic regression analyses adjusting for demographics, comorbidities, medications, and stent placement were used to examine the association between eGFR, receipt of clopidogrel, and death. Among 14,289 Veterans hospitalized with ACS, the prevalence of CKD was 54.1% and 14% died by 1- year after discharge. Compared with Veterans without CKD, those with CKD were more likely to have ACS involving myocardial infarction (88% v. 79%) but less likely to have percutaneous coronary intervention (26% v. 41%) including stent placement (25% v. 39%) and aspirin+clopidogrel at hospital discharge (55% v. 64%) (p < 0.05). In multivariable analysis, while a non-significant trend existed for a lesser odds of receipt of clopidogrel with CKD (OR: 0.92, 95% CI: 0.84-1.01), a significantly lesser odds of receipt of clopidogrel was found per 10 ml/min/m2 decrements in eGFR (OR: 0.97, 95% CI: 0.95- 0.99). In adjusted analysis, CKD was associated with a significantly increased odds of death (OR: 1.71, 95% CI: 1.49-1.96), while aspirin (OR: 0.85, 95% CI: 0.72-0.99) and clopidogrel (OR: 0.89, 95% CI: 0.79-1.00) were associated with decreased odds of death. In Veterans with ACS, lower levels of kidney function were associated with a lower receipt of beneficial antiplatelet medications and substantially higher mortality. Efforts are needed to improve processes of care and outcomes among adults with CKD after ACS.





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