Clopidogrel monotherapy is associated with better long-term outcomes than aspirin monotherapy when percutaneous coronary intervention (PCI) patients with diabetes have successfully completed dual antiplatelet therapy (DAPT), according to a new analysis published in JAMA Cardiology.[1] The study’s authors emphasized that this also appears to be true for patients who are not diabetic.
“Diabetes is a common comorbidity in patients with coronary artery disease,” wrote first author Tae-Min Rhee, MD, with Seoul National University College of Medicine in Korea, and colleagues. “Patients with diabetes compared to those without diabetes who received PCI are at increased risk of ischemic events such as coronary or cerebrovascular events as well as mortality.”
Rhee et al. examined data from the HOST-EXAM randomized clinical trial, focusing on more than 5,000 PCI patients who were treated at one of 37 centers in Korea from 2014 to 2018. All patients were free of clinical complications and completed DAPT as recommended after they underwent PCI.
The mean patient age of this group was 63.5 years old, and 25.5% were women. Patients were randomized to either receive clopidogrel monotherapy or aspirin monotherapy going forward as a part of their long-term treatment. A total of 34.2% of these patients presented with diabetes—including roughly 900 from both the clopidogrel monotherapy arm and the aspirin monotherapy arm.
Overall, the study’s primary endpoint—a composite of all-cause death, nonfatal myocardial infarction, stroke, hospital readmission due to acute coronary syndrome and major bleeding events after 24 months—was seen in 6.3% of clopidogrel patients with diabetes and 9.2% of aspirin patients with diabetes. In addition, that same endpoint was seen in 5.3% of clopidogrel patients without diabetes and 7% of aspirin patients without diabetes.
Also, the group noted that major adverse cardiovascular events (MACEs) were seen in 3.1% of clopidogrel patients with diabetes and 5.4% of aspirin patients with diabetes. Among patients without diabetes, the MACE rate was actually 3.1% for the clopidogrel patients and 3% for the aspirin patients.
“Diabetes may be associated with decreased efficacy in the antiplatelet effects of aspirin,” the authors wrote.
Another key takeaway was that diabetes did not appear to make clopidogrel monotherapy less effective at limiting thrombotic complications or bleeding events.
“The results of our study suggest that clopidogrel could be considered over aspirin for long-term maintenance antiplatelet therapy after PCI in both patients with and without diabetes,” the group concluded. “Although not significant due to insufficient statistical power in each group, the association of clopidogrel with reduced risk compared with aspirin was consistent for both thrombotic and bleeding outcomes in both the diabetes and no diabetes groups. The anticipated tradeoff between ischemic and bleeding risks was not observed in this study even in patients with diabetes.”
Michael has more than 16 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.