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Long-term Clopidogrel vs Aspirin Monotherapy in Coronary Artery Disease Patients With High Ischemic Risk: HOST-EXAM
Jin-Eun Song1, Han-Mo Yang2, Jeehoon Kang3
1Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea. Electronic address: https://x.com/Doctor_Ssong.
Insights
For stable coronary artery disease (CAD) patients, clopidogrel monotherapy is superior to aspirin. This holds true for those with high ischemic risk (HIR) and those without, reducing adverse clinical outcomes.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Medicine
Background:
- Optimal antiplatelet monotherapy for stable coronary artery disease (CAD) patients with high ischemic risk (HIR) remains unclear.
- Aspirin and clopidogrel are common antiplatelet agents, but their comparative long-term efficacy in specific patient subgroups requires further investigation.
Purpose of the Study:
- To compare the long-term clinical outcomes of aspirin versus clopidogrel monotherapy in stable CAD patients.
- To evaluate the efficacy of these antiplatelet agents in patients stratified by high ischemic risk (HIR).
Main Methods:
- Post hoc analysis of the HOST-EXAM Extended Study (NCT02044250).
- High ischemic risk (HIR) defined by specific clinical criteria including diabetes, chronic kidney disease, and complex PCI characteristics.
- Primary endpoint: composite of all-cause death, myocardial infarction, stroke, ACS readmission, and major bleeding.
Main Results:
- The primary endpoint occurred more frequently in the HIR arm (19.4%) compared to the non-HIR arm (13.9%).
- Clopidogrel monotherapy significantly reduced the risk of the primary endpoint in both HIR (16.4% vs. 23.2%) and non-HIR (12.1% vs. 15.7%) groups.
- No significant interaction was observed between HIR status and the antiplatelet strategy.
Conclusions:
- Clopidogrel monotherapy offers significant advantages over aspirin in reducing adverse clinical outcomes for stable CAD patients.
- These benefits are consistent across patients with and without high ischemic risk (HIR).
Background:
An optimal antiplatelet monotherapy agent for stable coronary artery disease (CAD) patients with high ischemic risk (HIR) is lacking. We analyzed the long-term outcomes between aspirin and clopidogrel monotherapy in a population of patients with CAD.
Methods:
The current study is a post hoc analysis of the HOST-EXAM Extended Study. HIR was defined as having a history of diabetes or chronic kidney disease, combined with at least 1 of the following: left main percutaneous coronary intervention, a bifurcation lesion treated with stents, a total stent length > 60 mm, at least 3 stents implanted, at least 3 lesions treated, or the presence of chronic total occlusion lesions. The primary endpoint was a composite of all-cause death, nonfatal myocardial infarction, stroke, readmission due to acute coronary syndrome, and major bleeding complications.
Results:
Of 4558 patients, the HIR arm included 803 patients and the non-HIR arm included 3755 patients. The primary endpoint was higher in the HIR arm compared with the non-HIR arm (19.4% vs 13.9%, hazard ratio [HR] 1.52, 95% confidence interval [CI] 1.37-1.68, P < 0.001). Clopidogrel monotherapy was associated with a lower risk of the primary endpoint in the HIR arm (16.4% vs 23.2%, HR 0.67, 95% CI 0.49-0.92, P = 0.014) and in the non-HIR arm (12.1% vs 15.7%, HR 0.74, 95% CI 0.64-0.87, P < 0.001). There was no significant interaction between HIR status and antiplatelet strategy (P for interaction = 0.53).
Conclusions:
In this long-term follow-up of stable CAD patients, clopidogrel monotherapy demonstrated significant advantages over aspirin in reducing adverse clinical outcomes, regardless of HIR status.
Clinical Trial Registration:
NCT02044250.
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