Aspirin vs clopidogrel in chronic coronary syndromes: a meta-analysis of ethnic differences
Claudio Laudani1,2, Giovanni Occhipinti3, Francesco Costa4,5
1Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA.
Insights
Clopidogrel shows better protection than aspirin for chronic coronary syndromes (CCS) patients, especially in East Asians. More research is needed for non-East Asian populations regarding cardiovascular event reduction.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Trials
Background:
- Chronic coronary syndromes (CCS) require effective secondary prevention strategies.
- Clopidogrel is emerging as a potentially superior antithrombotic agent compared to aspirin in CCS.
- Uncertainty exists regarding the consistency of clopidogrel's benefits across diverse ethnic groups.
Purpose of the Study:
- To compare the efficacy and safety of clopidogrel versus aspirin for secondary prevention in patients with CCS.
- To investigate the impact of ethnicity on the effectiveness of clopidogrel compared to aspirin.
- To assess the statistical power of existing trial data through subgroup analysis.
Main Methods:
- Systematic screening of randomized controlled trials (RCTs) comparing aspirin and clopidogrel in CCS patients.
- Primary endpoint analysis focused on major adverse cardiovascular events (MACE).
- Prespecified subgroup interaction analysis by ethnicity (East Asian vs. non-East Asian) and trial sequential analysis were conducted.
Main Results:
- Seven RCTs involving 30,165 patients (75.1% East Asian) were analyzed.
- Clopidogrel significantly reduced MACE (IRR 0.83) and net adverse clinical events compared to aspirin, with no increase in bleeding.
- Significant ethnic interaction observed: benefits were consistent in East Asians but not in non-East Asians for MACE and mortality.
Conclusions:
- Clopidogrel offers improved outcomes over aspirin for CCS secondary prevention, without increasing mortality.
- The evidence supporting clopidogrel's benefits is robust for East Asian populations.
- Further research is required to establish the efficacy of clopidogrel in non-East Asian CCS patients.
Background And Aims:
Emerging data suggest that, in patients with chronic coronary syndromes (CCS), clopidogrel provides superior antithrombotic protection compared with aspirin for secondary prevention, without an associated increase in bleeding risk. The consistency of the observed benefits across ethnicities remains uncertain.
Methods:
Randomized controlled trials (RCTs) comparing aspirin vs clopidogrel for secondary prevention in patients with CCS were screened. The primary endpoint was trial-defined major adverse cardiovascular events (MACE). Prespecified subgroup interaction by ethnicity (East Asian vs non-East Asian) was performed. Trial sequential analysis was used to assess the statistical power of the results.
Results:
Seven RCTs were included, encompassing 30 165 patients, of whom 75.1% were East Asians. Median follow-up was 36.0 months. Overall, clopidogrel was associated with significant reductions in MACE (incidence rate ratio [IRR] 0.83, 95% confidence interval [CI] 0.69-0.99) and net adverse clinical events (IRR 0.83, 95% CI 0.69-0.99), compared with aspirin. There were no differences between groups in major bleeding, myocardial infarction, or mortality. The results were consistent in the East Asian population, whereas a significant interaction by ethnicity was observed for MACE (East Asians: IRR 0.76, 95% CI 0.59-0.98; non-East Asians: IRR 1.00, 95% CI 0.74-1.36; Pint = 0.010) and mortality (Pint = 0.014), with no significant benefits observed in non-East Asian patients. The analyses were statistically powered for most outcomes in East Asian populations but for none in non-East Asian populations.
Conclusions:
In patients with CCS, the overall body of evidence suggests improved outcomes with clopidogrel compared with aspirin, without an apparent effect on mortality. However, a high level of confidence in these findings is currently limited to East Asian populations, and additional evidence is needed to clarify their applicability to non-East Asian patients.
Study Registration:
PROSPERO (CRD420251145176).
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