Ney Carter Borges: Clopidogrel vs Aspirin in Long-Term Monotherapy
Ney Carter Borges, Member Cardiologist of Global Physician Association at Cleveland Clinic Florida, shared a post on LinkedIn:
“HOST-EXAM 10-Year Study – ACC 26
The HOST-EXAM trial is a randomized, open-label, multicenter study evaluating the optimal long-term antiplatelet monotherapy after PCI with drug-eluting stents (DES). It compared clopidogrel versus aspirin in patients who remained event-free after 6–18 months of dual antiplatelet therapy (DAPT).
A total of 5,438 patients were randomized (2,710 clopidogrel vs. 2,728 aspirin), with a median follow-up of 10.5 years, representing one of the longest datasets in contemporary coronary intervention.
Key Results (10-year, intention-to-treat)
- Primary composite endpoint (POCO)
- Clopidogrel: 25.4%
- Aspirin: 28.5%
- HR 0.86 (95% CI 0.77–0.96), p=0.005
- Absolute risk reduction: 3.1%
- NNT ≈ 33
- Thrombotic events
- HR 0.82 (95% CI 0.72–0.93), p=0.002
- Any bleeding (BARC ≥2)
- HR 0.81 (95% CI 0.68–0.97), p=0.020
- Major bleeding (BARC ≥3)
- HR 0.71 (95% CI 0.57–0.88), p=0.002
- All-cause mortality
- No significant difference
- HR 1.07 (p=0.40)
Notably, stroke reduction—especially hemorrhagic stroke—was significantly lower with clopidogrel.
Per-Protocol Analysis (More pronounced effect)
Primary endpoint:
- 24.0% vs. 29.8%
- HR 0.76 (p<0.001)
- NNT ≈ 17
Consistent reductions in:
- MI
- Stroke (HR ~0.52)
- Bleeding events
Clinical Interpretation
This study challenges the traditional paradigm of aspirin as default lifelong therapy post-PCI.
Over a decade:
- Clopidogrel demonstrated sustained superiority
- Benefit was dual:
Decreased ischemic events
Decreased bleeding events - No mortality benefit, but clear reduction in morbidity
Importantly, benefits persisted beyond the randomized phase (post-trial period), reinforcing biological plausibility and durability of effect.
Limitations
- Open-label design (potential bias in softer endpoints)
- No pharmacogenetic testing (CYP2C19)
- Post-trial treatment heterogeneity
- Predominantly East Asian population (generalizability considerations)
Final Take-Home Message
In stable CAD patients post-PCI who are event-free after DAPT:
- Clopidogrel is superior to aspirin as long-term monotherapy
- Provides net clinical benefit (ischemia with bleeding)
- Should be strongly considered as preferred maintenance therapy”
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