Clopidogrel vs. aspirin: Tracking the chronic maintenance period after PCI for different risk groups
Long-term clopidogrel monotherapy is associated with key benefits over aspirin monotherapy when treating percutaneous coronary intervention (PCI) patients who have already undergone dual antiplatelet therapy for up to 18 months, according to new research published in JAMA Cardiology.[1]
The study’s authors noted that more and more patients are starting to undergo complex PCI. In addition, they added, the number of PCI patients facing a high bleeding risk (HBR) is also on the rise.
“Patients with HBR and/or undergoing complex PCI constitute the most complicated and challenging subsets of patients to manage, with a considerable portion of the PCI population falling into these high-risk categories,” wrote first author Jeehoon Kang, MD, with Seoul National University College of Medicine, and colleagues. “Despite the need for lifelong antiplatelet monotherapy in these patients, to our knowledge, no study to date has specifically addressed this issue during the chronic maintenance period.”
Kang et al. performed a post hoc analysis of the HOST-EXAM trial, tracking nearly 4,000 PCI patients who underwent treatment from 2014 to 2018 in South Korea. The mean patient age was 63.4 years old, 74.9% were men, 21.8% had a HBR and another 21.4% underwent complex PCI. Up to 5.9 years of follow-up data were available for these patients, and all of them maintained DAPT free of adverse events for six to 18 months.
Overall, the study’s thrombotic composite endpoint—cardiac death, nonfatal myocardial infarction, ischemic stroke, readmission due to acute coronary syndrome or definite/probable stent thrombosis—was significantly more common among HBR patients, but not significantly more common among complex PCI patients. Meanwhile, long-term treatment with clopidogrel monotherapy was associated with a lower risk of the study’s thrombotic composite endpoint than aspirin monotherapy. Bleeding events were also less likely among patients on clopidogrel monotherapy, including those with and without a HBR and those who did and did not undergo complex PCI.
“Overall, no significant interaction was found between treatment arms and risk groups, denoting that the beneficial impact of clopidogrel monotherapy was consistent regardless of HBR or PCI complexity,” the authors wrote. “However, the magnitude of thrombotic benefit of clopidogrel appeared to be greater numerically in the complex PCI group, although statistically insignificant. Greater adherence to clopidogrel, as compared with aspirin, may have contributed to such numerical difference, but additional evidence from other studies will be required to confirm these findings.”
Choosing to treat patients with long-term clopidogrel or aspirin monotherapy did not appear to have a significant impact on the risk of mortality, the group added.
“Although the analysis may not be powered to detect statistical differences in mortality, these results may support the safe use of clopidogrel compared with aspirin, even in the presence of clinical and procedural risk factors,” they wrote.
Click here to read the full analysis in JAMA Cardiology.
Michael has more than 18 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.