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Comparison of Antiplatelet Monotherapies After Percutaneous Coronary Intervention According to Clinical, Ischemic,
Seokhun Yang1, Jeehoon Kang1, Kyung Woo Park1
1Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
Insights
Clopidogrel is more effective than aspirin for secondary prevention after percutaneous coronary intervention (PCI). This benefit holds true for high-risk patients, demonstrating clopidogrel
Area of Science:
- Cardiology
- Pharmacology
- Clinical Trials
Background:
- Clopidogrel demonstrated superiority over aspirin monotherapy in secondary prevention following percutaneous coronary intervention (PCI).
- Understanding clopidogrel's benefits in high-risk patient subgroups is crucial for optimizing post-PCI care.
Purpose of the Study:
- To evaluate the efficacy of clopidogrel monotherapy compared to aspirin monotherapy in high-risk patients after PCI.
- To assess the consistency of clopidogrel's benefits across different risk strata defined by clinical scores.
Main Methods:
- Post hoc analysis of the HOST-EXAM trial involving patients event-free for 6-18 months post-PCI on dual antiplatelet therapy (DAPT).
- Patients were randomized to clopidogrel or aspirin monotherapy.
- Risk stratification used the DAPT score and Thrombolysis In Myocardial Infarction Risk Score for Secondary Prevention (TRS 2°P).
- Primary composite endpoint included all-cause death, nonfatal MI, stroke, ACS readmission, and major bleeding (BARC type ≥3) over 2 years.
Main Results:
- Clopidogrel monotherapy resulted in a significantly lower rate of the primary composite endpoint compared to aspirin monotherapy (HR: 0.73; 95% CI: 0.59-0.90).
- The benefit of clopidogrel was consistent across high and low TRS 2°P groups (P interaction=0.454) and high and low DAPT score groups (P interaction=0.662).
- Individual outcome analyses showed similar trends, supporting clopidogrel's advantage.
Conclusions:
- Clopidogrel monotherapy offers a consistent beneficial effect over aspirin monotherapy for secondary prevention after PCI.
- This advantage is maintained irrespective of patient's clinical risk profile or relative ischemic and bleeding risks.
Background:
Clopidogrel was superior to aspirin monotherapy in secondary prevention after percutaneous coronary intervention (PCI).
Objectives:
The purpose of this study was to evaluate the benefits of clopidogrel across high-risk subgroups METHODS: This was a post hoc analysis of the HOST-EXAM (Harmonizing Optimal Strategy for Treatment of coronary artery diseases-EXtended Antiplatelet Monotherapy) trial that randomly assigned patients who were event free for 6 to 18 months post-PCI on dual antiplatelet therapy (DAPT) to clopidogrel or aspirin monotherapy. Two clinical risk scores were used for risk stratification: the DAPT score and the Thrombolysis In Myocardial Infarction Risk Score for Secondary Prevention (TRS 2°P) (the sum of age ≥75 years, diabetes, hypertension, current smoking, peripheral artery disease, stroke, coronary artery bypass grafting, heart failure, and renal dysfunction). The primary composite endpoint was a composite of all-cause death, nonfatal myocardial infarction, stroke, readmission because of acute coronary syndrome, and major bleeding (Bleeding Academic Research Consortium type ≥3) at 2 years after randomization.
Results:
Among 5,403 patients, clopidogrel monotherapy showed a lower rate of the primary composite endpoint than aspirin monotherapy (HR: 0.73; 95% CI: 0.59-0.90). The benefit of clopidogrel over aspirin was consistent regardless of TRS 2°P (high TRS 2°P [≥3] group: HR: 0.65 [95% CI: 0.44-0.96]; and low TRS 2°P [<3] group: HR: 0.77 [95% CI: 0.60-0.99]) (P for interaction = 0.454) and regardless of DAPT score (high DAPT score [≥2] group: HR: 0.68 [95% CI: 0.46-1.00]; and low DAPT score [<2] group: HR: 0.75 [95% CI: 0.59-0.96]) (P for interaction = 0.662). The association was similar for the individual outcomes.
Conclusions:
The beneficial effect of clopidogrel over aspirin monotherapy was consistent regardless of clinical risk or relative ischemic and bleeding risks compared with aspirin monotherapy. (Harmonizing Optimal Strategy for Treatment of Coronary Artery Stenosis- EXtended Antiplatelet Monotherapy [HOST-EXAM]; NCT02044250).
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