Articulo Clopidogrel JACC Junio 08

Volume 51, Issue 23, June 10, 2008
CLINICAL RESEARCH: INTERVENTIONAL CARDIOLOGY
Long-Term Outcomes by Clopidogrel Duration and Stent Type in a Diabetic Population With De Novo Coronary Artery Lesions
Somjot S. Brar, MD*,*, John Kim, MD, Simerjeet K. Brar, BS, Ray Zadegan, MD, Michael Ree, BS, In-Lu A. Liu, MS, Prakash Mansukhani, MD, Vicken Aharonian, MD, Ric Hyett, BS and Albert Yuh-Jer Shen, MDObjectives: The purpose of this study was to determine whether long-term clinical outcomes differed between bare-metal stents (BMS) and drug-eluting stents (DES) by duration of clopidogrel use among diabetic patients.
Background: There is concern that DES are associated with late adverse events such as death and myocardial infarction (MI) secondary to stent thrombosis. However, data on outcomes in diabetic patients remain limited.
Methods: We identified 749 patients with diabetes mellitus who underwent stent implantation with either BMS (n = 251) or DES (n = 498) from October 2002 to December 2004. We performed survival analysis on the full cohort and on those event-free from death, MI, or repeat revascularization at 6 months (n = 671).
Results: By clopidogrel duration, the event rate for death or MI was 3.2% in the >9-month group, 9.4% in the 6- to 9-month group, and 16.5% in the <6-month>9-month group, 4.3% in the 6- to 9-month group, and 10.0% in the <6-month group, p < 0.001. When taking BMS clopidogrel non-users as a referent in the multivariate analysis, the hazard ratio (95% confidence interval [CI]) for death and nonfatal MI for DES clopidogrel users, DES clopidogrel nonusers, and BMS clopidogrel users were: HR 0.22 (95% CI 0.08 to 0.62, p = 0.005), HR 0.39 (95% CI 0.13 to 1.13, p = 0.08), and HR 0.25 (95% CI 0.08 to 0.81, p = 0.02), respectively.
Conclusions: Longer duration of clopidogrel use was associated with a lower incidence of death or MI in both the BMS and DES groups. Among clopidogrel nonusers, the incidence of death/MI or death did not differ by stent type.

COMENTARIOS de Dr Piñero:
- Estamos hablando de pacientes diabéticos, en donde más indicados están los DES (por la alta tasa de reestenosis que presentan estos pacientes)
- Cuánto mayor tiempo se use Clopidogrel parece que menor es la tasa de IAM/muerte TANTO para DES como BMS. PERO ¿por qué recomendaban tanto tiempo el clopidogrel a los paciente con BMS? (¿por ser SCA?, si es así habría que dar de todas todas 1 año de clopidogrel independeientemente del tipo del Stent, si no me equivoco)
- Aunque no se encuentran diferencias estadísticamente significativas de IAM/Mortalidad entre los pacientes que no toman clopidogrel, independientemente del tipo de Stent, sí que parece que existe un efecto favorable de los DES (a pesar de no tomar Clopidogrel; HR 0.39 (95% CI 0.13 to 1.13, p = 0.08)).
Esto podría ser importante y a discutir, porque en principio en todos los pacientes que no van a poder tomar clopidogrel ni se plantea el poner un DES- Se trata de un estudio observacional, no es un ensayo clínico, por lo que hay que tener cuidado con la interpretación de los resultados.