Aspirin vs Clopidogrel for Chronic Maintenance Monotherapy after PCI: Long-Term Outcomes
AHA Journals (Circulation): Published on November, 2022
Once patients have completed their
dual antiplatelet therapy, we need to stop one of the medications — which one
— ASA or clopidogrel? For many of us, we will keep the ASA and get rid of
the other agent like clopidogrel.
This study in Korea included 5438
patients who had PCI with drug-eluting stents (DES) and who had completed 6 to
18 months of dual antiplatelet therapy without any events.
TAKE-HOME MESSAGE
The authors of this HOST-EXAM
Extended study, compared the outcomes between daily 75-mg clopidogrel and 100-mg
aspirin monotherapy after coronary stenting.
The patients were randomized to
either ASA 100 mg or clopidogrel 75 mg to see which therapy was better at
blocking platelet action in the long run. After a median follow-up of 5.8
years, clopidogrel won over ASA
The primary outcome (all-cause
death, nonfatal myocardial infarction, stroke, readmission for acute coronary
syndrome, and BARC type ≥3 bleeding) was reduced by 26%. The actual percentage
of events was 16.9% for ASA and only 12.8% for the clopidogrel group.
The clopidogrel group had a lower risk for the secondary thrombotic endpoint (7.9% versus 11.9%) and secondary bleeding endpoint (4.5% versus 6.1%).
CONCLUSION
In the 5438 patients who were
event-free for 6 to 18 months after PCI, clopidogrel monotherapy significantly
reduced the risk of the composite of all-cause death, nonfatal myocardial
infarction, stroke, readmission owing to acute coronary syndrome, and major
bleeding compared with aspirin monotherapy.
There was a lower incidence of
discontinuation among those who received clopidogrel monotherapy.
These results show the potential
benefit of clopidogrel over aspirin for chronic maintenance of antiplatelet
monotherapy in patients after PCI.
Doctors Liked to Read More
Background: Long-term
outcomes of antiplatelet monotherapy in patients who receive percutaneous
coronary intervention are unknown. The HOST-EXAM (Harmonizing Optimal Strategy
for Treatment of Coronary Artery Stenosis-Extended Antiplatelet Monotherapy)
Extended study reports the posttrial follow-up results of the original
HOST-EXAM trial.
Methods: From March
2014 through May 2018, 5438 patients who maintained dual antiplatelet therapy
without clinical events for 12±6 months after percutaneous coronary
intervention with drug-eluting stents were randomly assigned in a 1:1 ratio to
receive clopidogrel (75 mg once daily) or aspirin (100 mg once daily). The
primary end point (a composite of all-cause death, nonfatal myocardial
infarction, stroke, readmission attributable to acute coronary syndrome, and
Bleeding Academic Research Consortium type 3 or greater bleeding), secondary
thrombotic end point (cardiac death, nonfatal myocardial infarction, ischemic
stroke, readmission attributable to acute coronary syndrome, and definite or
probable stent thrombosis), and bleeding end point (Bleeding Academic Research
Consortium type 2 or greater bleeding) were analyzed during the extended
follow-up period. Analysis was performed on the per-protocol population (2431
patients in the clopidogrel group and 2286 patients in the aspirin group).
Results: During a
median follow-up of 5.8 years (interquartile range, 4.8-6.2 years), the primary
end point occurred in 12.8% and 16.9% in the clopidogrel and aspirin groups,
respectively. The clopidogrel group had a lower risk for the secondary thrombotic
end point (7.9% versus 11.9%) and secondary bleeding end point (4.5% versus
6.1%). There was no significant difference in the incidence of all-cause death
between the 2 groups (6.2% versus 6.0%). Landmark analysis at 2 years showed
that the beneficial effect of clopidogrel was consistent throughout the
follow-up period.
Conclusions: During an
extended follow-up of >5 years after randomization, clopidogrel monotherapy
compared with aspirin monotherapy was associated with lower rates of the
composite net clinical outcome in patients without clinical events for 12±6
months after percutaneous coronary intervention with drug-eluting stents.
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