Long-Term Clopidogrel vs Aspirin Monotherapy in coronary artery disease patients with High Ischemic Risk: HOST-EXAM Extended Study Post Hoc Analysis

BACKGROUND: Optimal antiplatelet monotherapy agent for stable coronary artery disease (CAD) patients with high ischemic risk (HIR) is lacking. We analyzed the long-term outcomes between aspirin and clopidogrel monotherapy in this population. METHODS: The current study is a post hoc analysis of the HOST-EXAM Extended Study. HIR was defined as having a history of diabetes or chronic kidney disease, combined with at least one of the following: left main percutaneous coronary intervention, bifurcation lesion treated with stents, total stent length greater than 60 mm, at least 3 stents implanted, at least 3 lesions treated, or the presence of chronic total occlusion lesions. The primary endpoint was a composite of all-cause death, nonfatal myocardial infarction, stroke, readmission due to acute coronary syndrome, and major bleeding complications. RESULTS: Of 4558 patients, the HIR arm included 803 patients, and the non-HIR arm included 3755 patients. The primary endpoint was higher in the HIR arm compared to the non-HIR arm (19.4% vs. 13.9%, Hazard ratio (HR) 1.52 95% Confidence interval (CI), 1.37-1.68, p < 0.001). Clopidogrel monotherapy was associated with a lower risk of the primary endpoint in the HIR arm (16.4% vs. 23.2%, HR 0.67, 95% CI, 0.49-0.92, p=0.014), and in the non-HIR arm (12.1% vs. 15.7%, HR 0.74 95% CI, 0.64-0.87, p < 0.001). There was no significant interaction between HIR status and antiplatelet strategy (p for interaction=0.53). CONCLUSION: In this long-term follow-up of stable CAD patients, clopidogrel monotherapy demonstrated significant advantages over aspirin in reducing adverse clinical outcomes, regardless of the HIR status. CLINICAL TRIAL REGISTRATION: URL: https://www. CLINICALTRIALS: gov. Unique identifier: NCT02044250.