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Antiplatelet Therapy in Stable Coronary Artery Disease: A Systematic Review and Meta-Analysis

Rawan Mohammed Alzahrani1, Terad Talmesany2, Atheer Atiah Alghamdi1

  • 1Faculty of Medicine, Al Baha University, Al Baha, Saudi Arabia.

JACC. Advances
|March 30, 2026
PubMed

Insights

Clopidogrel monotherapy may be superior to aspirin for stable coronary artery disease (CAD). Anticoagulant monotherapy is recommended for atrial fibrillation with CAD, while intensified therapies require careful patient selection due to bleeding risks.

Area of Science:

  • Cardiology
  • Pharmacology
  • Clinical Trials

Background:

  • Stable coronary artery disease (CAD) impacts millions globally.
  • Emerging evidence questions aspirin monotherapy's standard role in antithrombotic treatment.
  • P2Y12 inhibitors and direct oral anticoagulants are key alternatives.

Purpose of the Study:

  • To assess antiplatelet strategies in stable CAD.
  • Compare monotherapy efficacy and safety.
  • Evaluate oral anticoagulant strategies for atrial fibrillation with CAD.
  • Examine intensified and diabetes-specific therapies.

Main Methods:

  • Systematic search of RCTs and observational studies up to May 2025.
  • Primary outcomes: major adverse cardiovascular events (MACE) and major bleeding.
  • Utilized random-effects meta-analyses, network meta-analysis, and meta-regression.

Main Results:

  • Clopidogrel showed superiority over aspirin in MACE and bleeding (2 RCTs).
  • Anticoagulant monotherapy demonstrated better efficacy and safety than combination therapy in atrial fibrillation with CAD (2 RCTs).
  • Intensified therapy reduced MACE but increased bleeding (4 RCTs).

Conclusions:

  • Clopidogrel monotherapy may offer advantages over aspirin in stable CAD.
  • Anticoagulant monotherapy is supported for atrial fibrillation with stable CAD post-revascularization.
  • Intensified strategies benefit select high-risk patients, requiring careful risk-benefit assessment.
Abstract

Keywords:
coronary artery diseasedirect oral anticoagulantsdual antiplatelet therapymajor adverse cardiovascular eventsstable coronary artery disease

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