Several antithrombotic agents commonly used by cardiologists during percutaneous coronary intervention (PCI) are not recommended for use in dialysis patients. Specifically, eptifibatide and enoxaparin are renally excreted and therefore not recommended for use in dialysis patients due to an increased risk of bleeding complications. Tsai and colleagues investigated the use of these agents amongst dialysis patients undergoing coronary intervention and their association with outcomes. The authors used data from 829 US hospitals on 22778 dialysis patients who underwent PCI between 2004 and 2008. The main outcome measure was in-hospital bleeding and death.
Overall, 5084 patients (22/3%) received a contra-indicated antithrombotic – 2375 (46/7%) received enoxaparin, 3261 (64.1%) received eptifibatide, and 552 patients (10.9%) received both. Compared with patients who did not receive a contraindicated antithrombotic, those who did showed higher rates of both in-hospital bleeding (5.6% vs. 2.9%; odds ratio 1.93) and death (6.5% vs. 3.9%; odds ratio 1.68). Following multi-variable adjustment, these risks remained high; odds ratio 1.66 for in-hospital bleeding and 1.24 for death for those who received contraindicated antithrombotics. Lastly, in 10158 patients matched using propensity scores, receipt of contraindicated antithrombotics remained significantly associated with in-hospital bleeding (odds ratio 1.63), but not in-hospital death (odds ratio 1.15).
The inappropriate use of eptifibatide and enoxaparin in patients with renal impairment is common. Furthermore, their use in this patient group is associated with a significantly increased risk of in-hospital bleeding. This issue is likely to become of even greater importance as the number of dialysis patients undergoing PCI is increasing.
• Tsai TT, Maddoz TM, Roe MT et al. Contraindicated medication use in dialysis patients undergoing percutaneous coronary intervention. JAMA 2009; 302:2458-2464.
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Dr Alistair C Lindsay, Dr Jonathan Spiro, Dr Hussain Contractor