A NEW comparative analysis has shown that clopidogrel monotherapy reduces thrombotic and bleeding risks more than aspirin after percutaneous coronary intervention (PCI), irrespective of high bleeding risk (HBR) or procedural complexity.
This post hoc analysis of the HOST-EXAM Extended trial evaluated 3,974 patients who had undergone PCI and remained event-free on dual antiplatelet therapy (DAPT) for 6–18 months. Participants were randomised to clopidogrel or aspirin monotherapy and followed for up to 5.9 years. The study focused on whether these antiplatelet therapies performed differently in patients with HBR and/or complex PCI. Coprimary outcomes were thrombotic events (cardiovascular death, myocardial infarction, stroke, acute coronary syndrome readmission, stent thrombosis) and bleeding events (Bleeding Academic Research Consortium types 2–5).
Among the 3,974 participants (mean age 63.4 years; 74.9% male), 21.8% had HBR, and 21.4% underwent complex PCI. Clopidogrel consistently showed better outcomes, with lower thrombotic event rates (hazard ratio [HR], 0.75; 95% CI, 0.53–1.04 for HBR; HR, 0.62; 95% CI, 0.48–0.80 for non-HBR) and bleeding event rates (HR, 0.82; 95% CI, 0.56–1.21 for HBR; HR, 0.58; 95% CI, 0.40–0.85 for non-HBR). Similarly, it outperformed aspirin in patients with complex PCI (HR, 0.49; 95% CI, 0.32–0.77 for thrombotic events; HR, 0.79; 95% CI, 0.47–1.33 for bleeding events). Interaction testing showed no significant effect modification by HBR or procedural complexity, supporting clopidogrel’s consistency across subgroups.
These findings suggest that clopidogrel monotherapy may be a superior long-term strategy for secondary prevention post-PCI, regardless of procedural complexity or bleeding risk. The consistent benefit across patient subgroups highlights its broad applicability in clinical practice. Future research should explore mechanisms underpinning these differences and assess potential variations across diverse populations. Implementing clopidogrel monotherapy could optimise patient outcomes while minimising risks, especially in those with complex clinical profiles.
Katrina Thornber, EMJ
Reference
Kang J et al. Long-term aspirin vs clopidogrel after coronary stenting by bleeding risk and procedural complexity. JAMA Cardiol. 2024;DOI:10.1001/jamacardio.2024.4030.
