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Randomized Controlled Trial
. 2023 Oct 17;82(16):1565-1578.
doi: 10.1016/j.jacc.2023.07.031.

Comparison of Antiplatelet Monotherapies After Percutaneous Coronary Intervention According to Clinical, Ischemic, and Bleeding Risks

Seokhun Yang  1 , Jeehoon Kang  1 , Kyung Woo Park  2 , Seung-Ho Hur  3 , Nam Ho Lee  4 , Doyeon Hwang  1 , Han-Mo Yang  1 , Hyo-Suk Ahn  5 , Kwang Soo Cha  6 , Sang-Ho Jo  7 , Jae Kean Ryu  8 , Il-Woo Suh  9 , Hyun-Hee Choi  10 , Seong-Ill Woo  11 , Jung-Kyu Han  1 , Eun-Seok Shin  12 , Bon-Kwon Koo  1 , Hyo-Soo Kim  1
Affiliations
Randomized Controlled Trial

Comparison of Antiplatelet Monotherapies After Percutaneous Coronary Intervention According to Clinical, Ischemic, and Bleeding Risks

Seokhun Yang et al. J Am Coll Cardiol. .

Abstract

Background: Clopidogrel was superior to aspirin monotherapy in secondary prevention after percutaneous coronary intervention (PCI).

Objectives: The purpose of this study was to evaluate the benefits of clopidogrel across high-risk subgroups METHODS: This was a post hoc analysis of the HOST-EXAM (Harmonizing Optimal Strategy for Treatment of coronary artery diseases-EXtended Antiplatelet Monotherapy) trial that randomly assigned patients who were event free for 6 to 18 months post-PCI on dual antiplatelet therapy (DAPT) to clopidogrel or aspirin monotherapy. Two clinical risk scores were used for risk stratification: the DAPT score and the Thrombolysis In Myocardial Infarction Risk Score for Secondary Prevention (TRS 2°P) (the sum of age ≥75 years, diabetes, hypertension, current smoking, peripheral artery disease, stroke, coronary artery bypass grafting, heart failure, and renal dysfunction). The primary composite endpoint was a composite of all-cause death, nonfatal myocardial infarction, stroke, readmission because of acute coronary syndrome, and major bleeding (Bleeding Academic Research Consortium type ≥3) at 2 years after randomization.

Results: Among 5,403 patients, clopidogrel monotherapy showed a lower rate of the primary composite endpoint than aspirin monotherapy (HR: 0.73; 95% CI: 0.59-0.90). The benefit of clopidogrel over aspirin was consistent regardless of TRS 2°P (high TRS 2°P [≥3] group: HR: 0.65 [95% CI: 0.44-0.96]; and low TRS 2°P [<3] group: HR: 0.77 [95% CI: 0.60-0.99]) (P for interaction = 0.454) and regardless of DAPT score (high DAPT score [≥2] group: HR: 0.68 [95% CI: 0.46-1.00]; and low DAPT score [<2] group: HR: 0.75 [95% CI: 0.59-0.96]) (P for interaction = 0.662). The association was similar for the individual outcomes.

Conclusions: The beneficial effect of clopidogrel over aspirin monotherapy was consistent regardless of clinical risk or relative ischemic and bleeding risks compared with aspirin monotherapy. (Harmonizing Optimal Strategy for Treatment of Coronary Artery Stenosis- EXtended Antiplatelet Monotherapy [HOST-EXAM]; NCT02044250).

Keywords: aspirin; bleeding; clopidogrel; ischemic events; percutaneous coronary intervention.

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Conflict of interest statement

Funding Support and Author Disclosures This work was supported by grants from the Patient-Centered Clinical Research Coordinating Center (grant number: HC19C0305). This research was partially supported by a grant from Seoul National University Hospital (Research ID: 30-2021-0030). The study funders had no role in trial design; data collection, analysis, interpretation, writing of the manuscript, or decision to submit the paper for publication. Dr Kim has received research grants or speaker fees from Daiichi-Sankyo, Boston Scientific, Terumo, Biotronik, Dio, Medtronic, Abbott Vascular, Edwards Lifesciences, Amgen, and Boehringer Ingelheim outside of the submitted work. Dr Park has received speaker fees from Daiichi-Sankyo, InnoN Pharmaceutical, and DaeWoong Pharmaceutical outside of the submitted work. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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