Department of Cardiology, Gentofte Hospital, Niels Andersens vej 65, 2900 Hellerup, Denmark.
JAMA. 2012 Sep 5;308(9):882-9. doi: 10.1001/2012.jama.10779.
Pharmacodynamic studies have shown that persistently high platelet reactivity is common in patients with diabetes in spite of clopidogrel treatment. Clinical trials have not convincingly demonstrated that clopidogrel benefits patients with diabetes as much patients without diabetes.
To estimate the clinical effectiveness associated with clopidogrel treatment after myocardial infarction (MI) in patients with diabetes.
DESIGN, SETTING, AND PATIENTS: By individual-level linkage of the Danish nationwide administrative registries between 2002-2009, patients who were hospitalized with incident MI and who had survived and not undergone coronary artery bypass surgery 30 days after discharge were followed up for as long as 1 year (maximally until December 31, 2009). Adjusted for age, sex, comorbidity, calendar year, concomitant pharmacotherapy, and invasive interventions, hazard ratios that were associated with clopidogrel in patients with and without diabetes were analyzed by Cox proportional-hazard models and propensity score-matched models.
All-cause mortality, cardiovascular mortality, and a composite end point of recurrent MI and all-cause mortality.
Of the 58,851 patients included in the study, 7247 (12%) had diabetes and 35,380 (60%) received clopidogrel. In total, 1790 patients (25%) with diabetes and 7931 patients (15%) without diabetes met the composite end point. Of these, 1225 (17%) with and 5377 (10%) without diabetes died. In total, 978 patients (80%) with and 4100 patients (76%) without diabetes died of events of cardiovascular origin. For patients with diabetes who were treated with clopidogrel, the unadjusted mortality rates (events/100 person-years) were 13.4 (95% CI, 12.8-14.0) vs 29.3 (95% CI, 28.3-30.4) for those not treated. For patients without diabetes who were treated with clopidogrel, the unadjusted mortality rates were 6.4 (95% CI, 6.3-6.6) vs 21.3 (95% CI, 21.0-21.7) for those not treated. However, among patients with diabetes vs those without diabetes, clopidogrel was associated with less effectiveness for all-cause mortality (HR, 0.89 [95% CI, 0.79-1.00] vs 0.75 [95% CI, 0.70-0.80]; P for interaction, .001) and for cardiovascular mortality (HR, 0.93 [95% CI, 0.81-1.06] vs 0.77 [95% CI, 0.72-0.83]; P for interaction, .01) but not for the composite end point (HR, 1.00 [95% CI, 0.91-1.10] vs 0.91 [95% CI, 0.87-0.96]; P for interaction, .08). Propensity score-matched models gave similar results.
Among patients with diabetes compared with patients without diabetes, the use of conventional clopidogrel treatment after MI was associated with lower reduction in the risk of all-cause death and cardiovascular death.
尽管使用了氯吡格雷治疗，但患有糖尿病的患者血小板反应性持续升高的情况在临床中很常见。临床试验尚未令人信服地证明氯吡格雷对糖尿病患者的益处与非糖尿病患者一样大。
评估心肌梗死后（MI）使用氯吡格雷治疗与糖尿病患者相关的临床疗效。
设计、设置和患者：通过丹麦全国行政登记处 2002-2009 年的个体水平链接，对因首发 MI 住院且出院后 30 天内未接受冠状动脉旁路手术并存活的患者进行了随访，随访时间最长为 1 年（最多至 2009 年 12 月 31 日）。通过 Cox 比例风险模型和倾向评分匹配模型，分析了糖尿病患者和非糖尿病患者中与氯吡格雷相关的风险比，调整了年龄、性别、合并症、日历年份、同时进行的药物治疗和有创干预。
全因死亡率、心血管死亡率和 MI 复发和全因死亡率的复合终点。
在纳入的 58851 例患者中，7247 例（12%）患有糖尿病，35380 例（60%）接受了氯吡格雷治疗。共有 1790 例（25%）糖尿病患者和 7931 例（15%）非糖尿病患者符合复合终点标准。其中，1225 例（17%）糖尿病患者和 5377 例（10%）非糖尿病患者死亡。共有 978 例（80%）糖尿病患者和 4100 例（76%）非糖尿病患者死于心血管原因。对于接受氯吡格雷治疗的糖尿病患者，未经调整的死亡率（每 100 人年的事件数）为 13.4（95%CI，12.8-14.0），而未治疗的患者为 29.3（95%CI，28.3-30.4）。对于接受氯吡格雷治疗的非糖尿病患者，未经调整的死亡率为 6.4（95%CI，6.3-6.6），而未治疗的患者为 21.3（95%CI，21.0-21.7）。然而，与非糖尿病患者相比，糖尿病患者使用氯吡格雷治疗全因死亡率（HR，0.89[95%CI，0.79-1.00] vs 0.75[95%CI，0.70-0.80]）和心血管死亡率（HR，0.93[95%CI，0.81-1.06] vs 0.77[95%CI，0.72-0.83]）的降低效果更差，但复合终点事件无差异（HR，1.00[95%CI，0.91-1.10] vs 0.91[95%CI，0.87-0.96]）（P 值交互作用，.001）。倾向评分匹配模型得出了相似的结果。
与非糖尿病患者相比，糖尿病患者在心肌梗死后使用常规氯吡格雷治疗与全因死亡和心血管死亡风险降低减少相关。
