Chinese clinical trials demonstrated that shortened dual antiplatelet therapy and P2Y12 inhibitor monotherapy after PCI significantly reduce bleeding without increasing ischemic events, e.g., OPT-BIRISK showed 25% lower bleeding risk and 26% lower major adverse events with clopidogrel monotherapy versus DAPT in high-risk ACS patients.
This review highlights the evolution of Chinese antithrombotic therapy for CAD from adopting international guidelines to generating robust domestic evidence that influences global practice.
The management of antithrombotic therapy represents a pivotal aspect in the treatment of coronary artery disease (CAD). In China, this field has evolved from a phase of learning from international evidence to a new era characterized by significant domestic innovation and contribution. This review systematically synthesizes the clinical evidence and advancements in antithrombotic strategies for CAD within the Chinese context, focusing on risk assessment, therapeutic optimization, and the standardization of clinical practice. The cornerstone of contemporary antithrombotic decision-making lies in the precise balance between ischemic and bleeding risks. Recognizing the limitations of applying Western-derived risk scores to the Chinese population due to genetic, lifestyle, and clinical practice differences, China has developed its own risk stratification tools. The OPT-CAD score, derived from a large, nationwide cohort, provides a more accurate prediction of long-term ischemic events and all-cause mortality for Chinese patients compared to the GRACE score. Similarly, the CAMI bleeding score outperforms traditional scores like CRUSADE in predicting in-hospital major bleeding after percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). These tools mark a critical transition from reliance on foreign models to the provision of locally validated rulers for risk assessment, enabling more tailored treatment strategies. In optimizing antithrombotic strategies, Chinese research has made substantial contributions to global guidelines, particularly in navigating the ischemia-bleeding trade-off. For antiplatelet therapy, the paradigm has shifted from a uniform, intense regimen to personalized, de-escalation approaches. Landmark Chinese studies, such as CREATE and I LOVE IT 2, have provided robust evidence for shortening dual antiplatelet therapy (DAPT) duration after implantation of specific drug-eluting stents. Furthermore, studies like TWILIGHT-China and ULTIMATE-DAPT have demonstrated the safety and efficacy of early transition to P2Y12 inhibitor monotherapy after a brief period (1–3 months) of DAPT in high-risk patients, reducing bleeding without increasing ischemic events. The OPT-BIRISK trial offered a novel strategy for patients with both high ischemic and high bleeding risk, showing the benefit of extended clopidogrel monotherapy after completing standard DAPT. Research has also extended to minimizing extracardiac harm, with the OPT-PEACE trial using novel endoscopic technology to quantify gastrointestinal injury from different antiplatelet regimens, informing safer drug selection. In addition, the OPTION trial suggested indobufen as a potential alternative to aspirin in combination with clopidogrel. Regarding periprocedural anticoagulation during PCI, Chinese-led trials have reshaped international perspectives. The BRIGHT study introduced an innovative strategy of post-PCI high-dose infusion of bivalirudin, which mitigated the increased acute stent thrombosis risk previously associated with this agent and significantly reduced bleeding. The subsequent BRIGHT-4 trial confirmed these benefits in a contemporary STEMI population, leading to upgraded recommendations in international guidelines. The standardization of clinical practice in China has been greatly advanced by the development and continuous updating of national guidelines and expert consensuses, which promote uniformity in treatment standards across different healthcare settings, guide individualized risk stratification, and ultimately drive continuous quality improvement in antithrombotic care for CAD patients nationwide. In the future, the antithrombotic therapy in China is oriented towards greater precision, safety, and accessibility. Key directions include leveraging big data and artificial intelligence to refine risk prediction and decision support, expanding high-quality real-world evidence, developing safer novel agents (e.g., vicagrel), and improving patient-centric management through digital health technologies. As the burden of CAD continues to grow with an aging population, China is poised to further integrate innovation, localization, and multidisciplinary collaboration to optimize antithrombotic strategies, aiming to improve patient outcomes and contribute Chinese wisdom to the global fight against cardiovascular disease.
Han et al. (Thu,) conducted a review in Coronary artery disease. Chinese clinical trials demonstrated that shortened dual antiplatelet therapy and P2Y12 inhibitor monotherapy after PCI significantly reduce bleeding without increasing ischemic events, e.g., OPT-BIRISK showed 25% lower bleeding risk and 26% lower major adverse events with clopidogrel monotherapy versus DAPT in high-risk ACS patients.