Clopidogrel edges out aspirin in heart procedure recovery

Researchers at 37 sites in South Korea have found patients taking clopidogrel after percutaneous coronary intervention (PCI) experienced lower rates of both thrombotic and bleeding events than those taking aspirin. Clopidogrel’s benefits remained consistent regardless of high bleeding risk (HBR) or complex PCI.

PCI (also called coronary angioplasty) is a treatment, typically involving a stent, to open an artery blocked by a buildup of plaques or to clear blockages after a heart attack. Complex PCI can involve the implantation of three or more stents.

Patients with HBR and those undergoing complex PCI procedures represent challenging populations with elevated risks of both blood clots and bleeding events.

Current guidelines recommend assessment of blood flow (ischemic risk) and bleeding risks when prescribing antiplatelet therapy for patients following PCI. While aspirin is traditionally the standard antiplatelet agent, recent studies suggest that P2Y12 inhibitors, such as clopidogrel, may be more effective for long-term secondary prevention.

In a post hoc analysis of the HOST-EXAM Extended study, “Long-Term Aspirin vs. Clopidogrel After Coronary Stenting by Bleeding Risk and Procedural Complexity,” published in JAMA Cardiology, researchers compared long-term outcomes of clopidogrel versus aspirin in patients across various bleeding risk and procedural complexities.

The analysis involved 3,974 stabilized patients across 37 sites in South Korea. Participants, all event-free after 6 to 18 months following PCI, were randomized 1:1 to receive either clopidogrel (75 mg daily) or aspirin (100 mg daily). Subgroups were classified based on HBR status and PCI complexity.

The study’s coprimary endpoints were thrombotic composite events (including cardiovascular death, nonfatal myocardial infarction, ischemic stroke, acute coronary syndrome readmission, blood clotting (stent thrombosis) and bleeding events.

Among the 3,974 participants (mean age, 63.4 years; 74.9% male), 21.8% were identified as HBR, and 21.4% underwent complex PCI.

Clopidogrel significantly reduced thrombotic composite events compared to aspirin in both HBR and non-HBR groups (HR: 0.75 for HBR; 0.62 for non-HBR) and in both complex and noncomplex PCI groups (HR: 0.49 for complex PCI; 0.74 for noncomplex PCI).

Bleeding risk was also lower with clopidogrel than aspirin, regardless of HBR status (HR: 0.82 for HBR; 0.58 for non-HBR) or PCI complexity (HR: 0.79 for complex PCI; 0.68 for noncomplex PCI).

Patients with both HBR and complex PCI experienced the most pronounced risk reductions with clopidogrel.

No significant interaction was observed between treatment effects and the presence of HBR or PCI complexity, indicating that clopidogrel’s superiority was consistent across all subgroups.

This post hoc trial analysis supports clopidogrel as the preferred monotherapy over aspirin for long-term secondary prevention in stabilized PCI patients. The findings are consistent across varying levels of procedural complexity and bleeding risk, suggesting that clopidogrel may offer broader benefits for high-risk cardiovascular patients during the chronic maintenance period.

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