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Use and outcomes of dual antiplatelet therapy for acute coronary syndrome in patients with chronic kidney disease: insights from the Canadian Observational Antiplatelet Study (COAPT)

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Abstract

Chronic kidney disease (CKD) increases the risk of adverse outcomes in acute coronary syndrome (ACS). The optimal regimen of dual antiplatelet therapy (DAPT) post-percutaneous coronary intervention (PCI) in CKD poses a challenge due to the increased bleeding and clotting tendencies, particularly since patients with CKD were underrepresented in randomized controlled trials. We examined the practice patterns of DAPT prescription stratified by the presence of CKD. The multicentre prospective Canadian Observational Antiplatelet Study (COAPT) enrolled patients with ACS between December 2011 and May 2013. The present study is a subgroup analysis comparing type and duration of DAPT and associated outcomes among patients with and without CKD (eGFR < 60 ml/min/1.73 m2, calculated by CKD-EPI). Patients with CKD (275/1921, 14.3%) were prescribed prasugrel/ticagrelor less (18.5% vs 25.8%, p = 0.01) and had a shorter duration of DAPT therapy versus patients without CKD (median 382 vs 402 days, p = 0.003). CKD was associated with major adverse cardiovascular events (MACE) at 12 months (p < 0.001) but not bleeding when compared to patients without CKD. CKD was associated with MACE in both patients on prasugrel/ticagrelor (p = 0.017) and those on clopidogrel (p < 0.001) (p for heterogeneity = 0.70). CKD was associated with increased bleeding only among patients receiving prasugrel/ticagrelor (p = 0.007), but not among those receiving clopidogrel (p = 0.64) (p for heterogeneity = 0.036). Patients with CKD had a shorter DAPT duration and were less frequently prescribed potent P2Y12 inhibitors than patients without CKD. Overall, compared with patients without CKD, patients with CKD had higher rates of MACE and similar bleeding rates. However, among those prescribed more potent P2Y12 inhibitors, CKD was associated with more bleeding than those without CKD. Further studies are needed to better define the benefit/risk evaluation, and establish a more tailored and evidence-based DAPT regimen for this high-risk patient group.

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Acknowledgements

The authors acknowledge editorial assistance by Sue Francis.

Funding

The COAPT study was sponsored by Eli Lilly and Daiichi Sankyo.

Author information

Authors and Affiliations

  1. University of Toronto, Toronto, Canada

    Carol Anne Graham, Akshay Bagai, Harold Fisher, Shaun G. Goodman & Andrew T. Yan

  2. Canadian Heart Research Centre, Toronto, Canada

    Mary K. Tan & Shaun G. Goodman

  3. College of Medicine & Public Health, Flinders University, Adelaide, Australia

    Derek P. Chew

  4. University of Leeds, Leeds, UK

    Christopher P. Gale

  5. Center for Cardiovascular Science, University of Edinburgh, Edinburgh, UK

    Keith A. A. Fox

  6. St Michael’s Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada

    Akshay Bagai, Shaun G. Goodman & Andrew T. Yan

  7. Health Sciences North, Sudbury, Canada

    Mark A. Henderson

  8. Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, Canada

    Ata ur Rehman Quraishi

  9. Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec, Canada

    Jean-Pierre Déry & Tomas Cieza

  10. Southlake Regional Health Centre, Newmarket, Canada

    Asim N. Cheema

  11. Medcan Clinic, Toronto, Canada

    Harold Fisher

  12. Concord Hospital, University of Sydney, Sydney, Australia

    David Brieger

  13. New Brunswick Heart Centre, Dalhousie University, Saint John, Canada

    Sohrab R. Lutchmedial

  14. London Health Sciences Centre, Western University, London, Canada

    Shahar Lavi

  15. Health Sciences North, Northern Ontario School of Medicine, Sudbury, Canada

    Brian Y. L. Wong

  16. Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Canada

    Shamir R. Mehta

  17. Royal Alexandra Hospital, Edmonton, Canada

    Neil Brass

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  1. Carol Anne Graham
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Correspondence to Andrew T. Yan.

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Graham, C.A., Tan, M.K., Chew, D.P. et al. Use and outcomes of dual antiplatelet therapy for acute coronary syndrome in patients with chronic kidney disease: insights from the Canadian Observational Antiplatelet Study (COAPT). Heart Vessels 37, 1291–1298 (2022). https://doi.org/10.1007/s00380-022-02029-8

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