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Optimal Long-term Antiplatelet Regimen for Patients with High Ischaemic and Bleeding Risks After Percutaneous

Jeong Yoon Jang1, Ga-In Yu1, Jongwha Ahn1

  • 1Cardiovascular Centre, Department of Internal Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea.

Thrombosis and Haemostasis
|December 10, 2024
PubMed

Insights

For patients with high risks of both bleeding and ischemia after percutaneous coronary intervention (PCI), clopidogrel monotherapy offers a superior long-term antiplatelet strategy compared to dual antiplatelet therapy (DAPT). This approach significantly reduces the composite endpoint of death, myocardial infarction, or stroke.

Area of Science:

  • Cardiology
  • Interventional Cardiology
  • Pharmacology

Background:

  • Patients undergoing percutaneous coronary intervention (PCI) often face a dual risk of ischemic events and bleeding complications.
  • Optimizing long-term antiplatelet therapy is crucial for balancing efficacy and safety in high-risk populations.
  • Current strategies often involve dual antiplatelet therapy (DAPT), but its long-term use can increase bleeding risk.

Purpose of the Study:

  • To evaluate the optimal long-term antiplatelet strategy for patients at high risk of both ischemia and bleeding after PCI.
  • To compare the clinical outcomes of clopidogrel monotherapy (CLPD), aspirin monotherapy (ASA), and DAPT in this specific patient group.

Main Methods:

  • A cohort study design was employed, including patients with high ischemic and bleeding risks who completed a mandatory DAPT period without complications.
  • Clinical outcomes were assessed across three treatment groups: CLPD, ASA, and DAPT.
  • Stabilized inverse probability treatment weighting (IPTW) was used to adjust for baseline characteristics and balance treatment groups.

Main Results:

  • After IPTW adjustment, clopidogrel monotherapy (CLPD) showed a significantly lower rate of the primary composite endpoint (all-cause death, myocardial infarction, stroke, or major bleeding) compared to DAPT (HR=2.09, p=0.008).
  • No significant difference was observed between CLPD and aspirin monotherapy (ASA) (HR=1.46, p=0.187).
  • The benefit of CLPD over DAPT was primarily driven by a reduction in ischemic events (HR=2.51, p=0.003), with a trend towards lower bleeding incidence (HR=2.51, p=0.096).

Conclusions:

  • Clopidogrel monotherapy demonstrates a significant net clinical benefit for patients at high risk of both bleeding and ischemia, particularly after complex PCI.
  • This strategy appears superior to DAPT in reducing the composite endpoint, mainly due to fewer ischemic events.
  • Clopidogrel monotherapy also showed a numerical reduction in both bleeding and ischemic events compared to aspirin monotherapy.

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