Clopidogrel vs Aspirin Monotherapy Beyond 1 Year After Percutaneous Coronary Intervention

• Published in: Journal of the American College of Cardiology Vol. 83; no. 1; pp. 17 - 31
• Main Authors: Watanabe, Hirotoshi, Morimoto, Takeshi, Natsuaki, Masahiro, Yamamoto, Ko, Obayashi, Yuki, Nishikawa, Ryusuke, Ando, Kenji, Ono, Koh, Kadota, Kazushige, Suwa, Satoru, Morishima, Itsuro, Yoshida, Ruka, Hata, Yoshiki, Akao, Masaharu, Yagi, Masahiro, Suematsu, Nobuhiro, Morino, Yoshihiro, Yokomatsu, Takafumi, Takamisawa, Itaru, Noda, Toshiyuki, Doi, Masayuki, Okayama, Hideki, Nakamura, Yuichi, Hibi, Kiyoshi, Sakamoto, Hiroki, Noguchi, Teruo, Kimura, Takeshi
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 02.01.2024
• Subjects: antiplatelet therapy; bleeding; coronary stent; P2Y12 inhibition; percutaneous coronary intervention; percutaneous coronary intervention; bleeding; PCI; ITT; PPI; coronary stent; P2Y12 inhibition; antiplatelet therapy; DAPT; P2Y inhibition
• ISSN: 0735-1097; 1558-3597; 1558-3597
• DOI: 10.1016/j.jacc.2023.10.013

It remains unclear whether clopidogrel is better suited than aspirin as the long-term antiplatelet monotherapy following dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI). This study compared clopidogrel monotherapy following 1 month of DAPT (clopidogrel group) with aspirin monotherapy following 12 months of DAPT (aspirin group) after PCI for 5 years. STOPDAPT-2 (Short and Optimal Duration of Dual Antiplatelet Therapy 2) is a multicenter, open-label, adjudicator-blinded, randomized clinical trial conducted in Japan. Patients who underwent PCI with cobalt-chromium everolimus-eluting stents were randomized in a 1-to-1 fashion either to clopidogrel or aspirin groups. The primary endpoint was a composite of cardiovascular outcomes (cardiovascular death, myocardial infarction, stroke, or definite stent thrombosis) or major bleeding (TIMI major or minor bleeding). Among 3,005 study patients (age: 68.6 ± 10.7 years; women: 22.3%; acute coronary syndrome: 38.3%), 2,934 patients (97.6%) completed the 5-year follow-up (adherence to the study drugs at 395 days: 84.7% and 75.9%). The clopidogrel group compared with the aspirin group was noninferior but not superior for the primary endpoint (11.75% and 13.57%, respectively; HR: 0.85; 95% CI: 0.70-1.05; Pnoninferiority < 0.001; Psuperiority = 0.13), whereas it was superior for the cardiovascular outcomes (8.61% and 11.05%, respectively; HR: 0.77; 95% CI: 0.61-0.97; P = 0.03) and not superior for major bleeding (4.44% and 4.92%, respectively; HR: 0.89; 95% CI: 0.64-1.25; P = 0.51). By the 1-year landmark analysis, clopidogrel was numerically, but not significantly, superior to aspirin for cardiovascular events (6.79% and 8.68%, respectively; HR: 0.77; 95% CI: 0.59-1.01; P = 0.06) without difference in major bleeding (3.99% and 3.32%, respectively; HR: 1.23; 95% CI: 0.84-1.81; P = 0.31). Clopidogrel might be an attractive alternative to aspirin with a borderline ischemic benefit beyond 1 year after PCI. [Display omitted]