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Long-term Clopidogrel vs. Aspirin After Coronary Stenting


Core Concepts
Clopidogrel shows superiority over aspirin in reducing secondary endpoints post-coronary stenting.
Abstract
TOPLINE: Clopidogrel noninferior to aspirin for net adverse clinical events at 5 years post-PCI. Clopidogrel superior to aspirin in reducing MI and ischemic stroke. METHODOLOGY: STOPDAPT-2 trial: Clopidogrel monotherapy after 1 month of DAPT reduces major bleeding without increased cardiovascular events. 5-year results in 3005 patients: clopidogrel group vs. aspirin group. TAKEAWAY: Clopidogrel group noninferior for primary endpoint, superior for major secondary cardiovascular endpoint. No significant difference in major secondary bleeding or newly diagnosed cancer. IN PRACTICE: Clopidogrel may be a better option than aspirin post-PCI for long-term ischemic protection. DAPT de-escalation to P2Y 12 inhibitor alone could become standard care. SOURCE: Study by Hirotoshi Watanabe, MD, published in the Journal of the American College of Cardiology. LIMITATIONS: Adherence to antiplatelet therapy over 80%, but changes in therapy for clinical events. Study only included Japanese patients, potential risk differences across ethnicities. Lack of data on non-antithrombotic medications and cost-effectiveness analysis. DISCLOSURES: Bellemain-Appaix received lecture fees from Novartis, Biotronik, AstraZeneca, and BMS/Pfizer.
Stats
"Clopidogrel group was noninferior, but not superior, to the aspirin group for the primary endpoint (11.75% vs 13.57%; hazard ratio [HR], 0.85; 95% CI, 0.70-1.05; P for noninferiority < .001; P for superiority = .13)." "The clopidogrel group was superior to the aspirin group for the major secondary cardiovascular endpoint (8.61% vs 11.05%; HR, 0.77; 95% CI, 0.61-0.97; P for noninferiority < .001; P for superiority = .03)." "The cumulative 5-year incidence of major secondary bleeding was not lower in the clopidogrel group (4.44% vs 4.92%; HR, 0.89; 95% CI, 0.64-1.25; P = .51)."
Quotes
"Clopidogrel might be an attractive alternative to aspirin with a borderline ischemic benefit beyond 1 year after PCI." "This important study confirms that ischemic protection post-PCI is better ensured by clopidogrel than aspirin from 1 month to 5 years."

Deeper Inquiries

How might the findings of this study impact current guidelines for post-PCI antiplatelet therapy

The findings of this study could potentially impact current guidelines for post-PCI antiplatelet therapy by suggesting that clopidogrel may be a more beneficial option compared to aspirin, especially beyond the first year after PCI. The study showed that clopidogrel was noninferior to aspirin for net adverse clinical events and superior in reducing secondary endpoints of myocardial infarction and ischemic stroke. These results may prompt a reevaluation of the standard practice of using aspirin post-PCI and could lead to a shift towards clopidogrel as the preferred antiplatelet therapy in certain patient populations.

What potential challenges could arise in implementing clopidogrel as the preferred option over aspirin

Implementing clopidogrel as the preferred option over aspirin post-PCI may present some challenges. One potential challenge could be related to cost-effectiveness, as aspirin is relatively inexpensive compared to clopidogrel. Without a formal cost-effectiveness analysis, it may be difficult to justify the adoption of clopidogrel as a lifelong treatment option. Additionally, there may be concerns regarding patient adherence and compliance with clopidogrel therapy, especially if it involves long-term use. Monitoring and ensuring patient adherence to clopidogrel treatment could be a challenge in real-world clinical settings.

How could the study's focus on Japanese patients influence the generalizability of the results to other populations

The study's focus on Japanese patients may limit the generalizability of the results to other populations. Differences in genetic factors, lifestyle, and healthcare practices among different ethnicities could impact the efficacy and safety of clopidogrel compared to aspirin in patients from other regions. It is essential to consider these factors when extrapolating the study findings to a more diverse patient population. Further research involving a more diverse patient cohort would be necessary to determine the broader applicability of using clopidogrel as the preferred antiplatelet therapy post-PCI.
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