Clopidogrel monotherapy bests aspirin when patients with diabetes undergo PCI
After patients with diabetes undergo percutaneous coronary intervention (PCI) and then complete an initial period of dual antiplatelet therapy (DAPT). The question is often what is the next step, should they move on to clopidogrel monotherapy or aspirin monotherapy?
According to new findings published in JACC: Cardiovascular Interventions, starting those patients on clopidogrel monotherapy instead of aspirin appears to be the most beneficial approach.[1]
Looking back at SMART-CHOICE 3
In the SMART-CHOICE 3 trial, researchers found that clopidogrel monotherapy was associated with key benefits over aspirin monotherapy for PCI patients after an initial period of DAPT.[2] However, it was unclear if this also applied specifically to patients presenting with diabetes.
“Diabetes mellitus has been one of the major cardiovascular comorbidities, and it was one of the major enrollment criteria of the SMART-CHOICE 3 trial to define high-risk clinical characteristics,” wrote first author Sang Yoon Lee, MD, PhD, a researcher with Samsung Medical Center and the Sungkyunkwan University School of Medicine in South Korea, and colleagues. “Given the increased ischemic and bleeding susceptibility in patients with complex coronary lesions or high-risk clinical characteristics, it is clinically important to evaluate which monotherapy would be better for long-term clinical outcomes.”
A new perspective
Lee et al. explored the SMART-CHOICE 3 data again with a special focus on the more than 2,000 patients who had diabetes when they underwent PCI. The median follow-up period was 2.3 years.
The primary endpoint of SMART-CHOICE 3 was major adverse cardiac and cerebrovascular events (MACCE), a composite outcome that included all-cause mortality, myocardial infarction and stroke. The MACCE rate was 6.8% for patients with diabetes and 4.7% for patients without diabetes.
Looking specifically at what patients with diabetes were prescribed following DAPT, the MACCE rate was 4.5% for the clopidogrel group and 9.1% for the aspirin group. In addition, the clopidogrel patients were linked to a lower risk of myocardial infarction than the aspirin patients (0.9% vs. 3.6%). The risk of bleeding, on the other hand, was identical for the two groups.
“These findings demonstrate that clopidogrel would be preferred monotherapy than aspirin among diabetes mellitus patients after completion of a standard duration of DAPT after PCI,” the authors wrote.
The authors added that this benefit for clopidogrel monotherapy was even more pronounced for patients with poor glycemic control and patients who present with multiple risk factors.
“These results may suggest that clopidogrel monotherapy could be individualized based on glycemic control status or the presence of additional risk factors, rather than being routinely adopted for all diabetes mellitus patients undergoing PCI,” they added.
Click here for the full analysis in JACC: Cardiovascular Interventions, an American College of Cardiology journal.
Michael has more than 19 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.