Clopidogrel superior to aspirin in reducing adverse events after PCI with DES: Lancet

Clopidogrel monotherapy reduced long-term rates of all-cause mortality, non-fatal myocardial infarction, and stroke after drug-eluting stent placement compared with aspirin monotherapy.

The superiority of clopidogrel was seen for both thrombotic and bleeding endpoints and was consistent across demographic groups.

South Korea: Clopidogrel monotherapy is beneficial over aspirin monotherapy during the chronic maintenance period in patients who undergo coronary stenting, according to results from HOST-EXAM -- an investigator-initiated, prospective, randomized, open-label, multicentre trial conducted at 37 study sites in South Korea.  

"Clopidogrel monotherapy was superior to aspirin monotherapy in preventing future adverse clinical events in patients requiring indefinite antiplatelet monotherapy after percutaneous coronary intervention," wrote the authors. 

The study showed that clopidogrel monotherapy significantly reduced the risk of the composite of all-cause death, non-fatal myocardial infarction, stroke, readmission due to acute coronary syndrome, and BARC bleeding type 3 or greater. 

Bon-Kwon Koo, Seoul National University Hospital, Seoul, South Korea, and colleagues aimed to compare head to head the efficacy and safety of aspirin and clopidogrel monotherapy during the chronic maintenance period in patients undergoing coronary stenting. 

The researchers enrolled patients aged at least 20 years who maintained dual antiplatelet therapy without clinical events for 6–18 months after percutaneous coronary intervention with drug-eluting stents (DES). Patients with any ischaemic and major bleeding complications were excluded. 5438 patients were randomly assigned in a ratio of 1:1 to receive a monotherapy of clopidogrel 75 mg once daily (n=2710) or aspirin 100 mg (n=2728) once daily for 24 months.

The primary endpoint was a composite of all-cause death, non-fatal myocardial infarction, stroke, readmission due to acute coronary syndrome, and Bleeding Academic Research Consortium (BARC) bleeding type 3 or greater, in the intention-to-treat population. 

The researchers found that ascertainment of the primary endpoint was completed in 98·2%)patients. During 24-month follow-up, the primary outcome occurred in 5·7% patients in the clopidogrel group and 7·7% in the aspirin group (hazard ratio 0·73).

"Clopidogrel monotherapy, compared with aspirin monotherapy during the chronic maintenance period after percutaneous coronary intervention with DES significantly reduced the risk of the composite of all-cause death, non-fatal myocardial infarction, stroke, readmission due to acute coronary syndrome, and BARC bleeding type 3 or greater," concluded the authors. 

Reference:

The study titled, "Aspirin versus clopidogrel for chronic maintenance monotherapy after percutaneous coronary intervention (HOST-EXAM): an investigator-initiated, prospective, randomised, open-label, multicentre trial," is published in The Lancet.

DOI: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)01063-1/fulltext