Higher Bleeding Risk, Early Antiplatelet Cessation Seen in CKD Patients

Not much is known about the incidence of post-MI bleeding in CKD patients
Not much is known about the incidence of post-MI bleeding in CKD patients

WASHINGTON, DC—At the ACC.17 Scientific Session, Jennifer Rymer, from Duke University, Durham, NC, presented that chronic kidney disease (CKD) was associated with an increased risk of bleeding and premature discontinuation of P2Y12 inhibitor therapy after discharge in percutaneous coronary intervention (PCI)-treated myocardial infarction (MI) patients.

Although MI is known to be common among patients with CKD, not much is known about the incidence of post-MI bleeding and premature P2Y12 inhibitor therapy cessation among these patients. Rymer and coauthors studied MI patients treated with PCI and discharged with P2Y12 inhibitor therapy across U.S. hospitals in the TRANSLATE-ACS study. They measured the incidence of GUSTO severe/moderate bleeding within 1 year of discharge and rate of P2Y12 inhibitor discontinuation (and stent type) were compared for patients with creatinine clearance (CrCl) <30mL/min (dialysis), 30–59mL/min, 60–89mL/min, and ≥90mL/min. 

Of the total 11,108 PCI-treated MI patients, 4% exhibited CrCl <30mL/min, 27% had CrCl 30–59mL/min, and 42% had CrCl 60–89mL/min. Rymer said, "Higher potency P2Y12 inhibitors were less likely to be prescribed to patients with lower CrCl but was used in 22% of patients with CrCl <60mL/min."

Patients with lower CrCl showed greater unadjusted and adjusted risk of GUSTO severe/moderate bleeding (P<0.001): patients with CrCl 60–89mL/min had a 2.1% cumulative incidence (adjusted HR [aHR] 1.61, 95% CI: 1.05–2.45); patients with CrCl 30–59mL/min had a 4.1% cumulative incidence (aHR 1.92 95% CI: 1.21–3.02); patients with CrCl <30mL/min (dialysis) had a cumulative incidence of 10.0% (aHR 2.44, 95% CI: 1.40–4.23). 

Patients with CrCl <30mL/min exhibited higher rates of premature P2Y12 inhibitor discontinuation and shorter time to P2Y12 inhibitor discontinuation (P=0.64): patients with CrCl 60-89mL/min had a 15.1% discontinuation rate; patients with CrCl 30–59mL/min had a 15.5% discontinuation rate; and patients with CrCl <30mL/min (dialysis) had a 16.8% discontinuation rate. Discontinuation was defined as cessation of any P2Y12 inhibitor for >7 days. 

Patients with CrCl <30mL/min exhibited higher rates of premature P2Y12 inhibitor discontinuation and a shorter time to P2Y12 inhibitor discontinuation. Moreover, interruptions in P2Y12 inhibitor therapy due to bleeding were more common among patients with lower CrCl despite P2Y12 inhibitor type. 

Rymer concluded, "CKD is common among PCI-treated MI patients and [is] associated with higher risk of bleeding and premature cessation of P2Y12 inhibitor treatment post-discharge."