Written by Babatunde Carew
Spoon Feed
In high-risk post-percutaneous coronary intervention (PCI) patients who have completed dual antiplatelet therapy (DAPT), clopidogrel monotherapy compared to aspirin significantly reduced major adverse cardiac and cerebrovascular events without increasing bleeding risk.
Platelet it be known – clopidogrel wins this round
Current guidelines recommend a defined duration of DAPT after PCI, given the known risks of premature discontinuation – including stent thrombosis and death – but the optimal long-term antiplatelet monotherapy strategy following DAPT remains uncertain.
This randomized, open-label, multicenter trial (SMART-CHOICE 3) evaluated clopidogrel versus aspirin monotherapy in 5,506 South Korean, high-CV-risk patients post-PCI who completed standard DAPT. Over a 2.3 year median follow-up period, clopidogrel significantly reduced the composite outcome of death, MI, or stroke (HR 0.71, 95%CI 0.54–0.93, p=0.013) without increasing bleeding risk compared to aspirin. Limitations include open-label design, relatively short follow-up period, and exclusive enrollment of Korean patients.
How does this change my practice?
This study does change my practice. I have typically favored aspirin over clopidogrel for monotherapy following DAPT post-PCI, largely due to the observed standard practices during my training. While further studies are warranted, these findings suggest clopidogrel may offer superior cardiovascular outcomes in this setting, making me more inclined to consider it as the preferred option. Given the relatively common practice of prolonged DAPT in high-risk post PCI patients, future trials comparing monotherapy with aspirin, clopidogrel, and prasugrel vs. continued DAPT in this population would be valuable.
Source
Efficacy and safety of clopidogrel versus aspirin monotherapy in patients at high risk of subsequent cardiovascular event after percutaneous coronary intervention (SMART-CHOICE 3): a randomised, open-label, multicentre trial. Lancet. 2025 Apr 12;405(10486):1252-1263. doi: 10.1016/S0140-6736(25)00449-0. Epub 2025 Mar 30. PMID: 40174599
