“Bleeding hazards and lack of clear efficacy in reducing cardiovascular morbidity and mortality need to be acknowledged when patients with CKD are being counseled about acute or long-term antiplatelet therapy,” the authors advise.
Dr. Giovanni F. M. Strippoli, with the Consorzio Mario Negri Sud in Santa Maria Imbaro, Italy, and colleagues explain that extrapolating the benefits of antiplatelet therapy to CKD patients is problematic because atherosclerotic cardiac disease is relatively uncommon in this population while the risk of bleeding may be greater due to impaired hemostasis.
To summarize the benefits and harms of antiplatelet therapy in CKD patients, the team identified 40 trials of antiplatelet agents compared to standard care, placebo or no treatment that included adults with CKD. Nine trials involved a total of 9969 patients with ACS or who underwent PCI, while 31 trials included 11,701 patients at risk for or with stable cardiovascular disease.
Among CKD patients in the ACS/PCI cohort, glycoprotein IIb/IIIa inhibitors or clopidogrel had little effect on cardiovascular mortality (relative risk 0.96) or MI (RR 0.89), but increased serious bleeding (RR 1.40), compared to standard care, the authors found.
In the cohort at risk for or with stable CVD, antiplatelet therapy did reduce the risk of MI (RR 0.66) in CKD patients, but the effects on cardiovascular mortality were uncertain (RR 0.91). The risk of minor bleeding was also increased (RR 1.70), although the evidence was generally of low quality, Dr. Strippoli and colleagues report.
Summing up, they conclude, ”Benefits for antiplatelet therapy among persons with CKD are uncertain and are potentially outweighed by bleeding hazards.”
Ann Intern Med 2012; 156:445-459.