April 27, 2026The Lancet
Aspirin versus clopidogrel for chronic maintenance monotherapy after percutaneous coronary intervention: 10-year follow-up of the HOST-EXAM trial
Key result
Clopidogrel monotherapy reduces major events ~14% vs aspirin over 10 years post-PCI.
- HR 0.86
- 95% CI 0.77-0.96
- P=0.0050
- n=5,438
Why the study?
The long-term clinical outcomes of clopidogrel versus aspirin monotherapy after PCI remain uncertain.
Does clopidogrel reduce the composite of all-cause death, non-fatal myocardial infarction, stroke, readmission due to acute coronary syndrome, and BARC type ≥3 bleeding compared to aspirin in patients who completed event-free dual antiplatelet therapy for 6-18 months after PCI?
Population
5438 patients event-free on DAPT for 6-18 months after PCI
Comparison
Clopidogrel 75 mg once daily vs aspirin 100 mg once daily
Design
Randomized controlled trial (10-year extended follow-up)
Follow-up
Median 10.5 years
Authors
Discussion
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Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“These findings suggest that clopidogrel might be considered as a preferred agent for long-term antiplatelet monotherapy during the chronic maintenance phase after PCI. The substantial reduction in the cost of clopidogrel over the past three decades, together with the positive long-term results from the current study, warrants a reappraisal of the benefits of clopidogrel over aspirin.”
“This is the first study providing a long-term comparison between the two most commonly used antiplatelet agents, and it shows a sustained benefit of clopidogrel monotherapy for lifelong secondary prevention, a finding that is particularly relevant for young patients with a long life expectancy.”
“Clinicians should be aware that patients in East Asia (where the trial was conducted) have a high prevalence of CYP2C19 loss-of-function alleles (affecting clopidogrel metabolism) but actually experience lower thrombotic rates than Western populations.”
Implication
Supports clopidogrel over aspirin for long-term post-PCI monotherapy; extends HOST-EXAM RCT to 10 years.
Key Points
- This research evaluates the long-term effects of clopidogrel versus aspirin monotherapy after percutaneous coronary intervention (PCI).
- Randomized trial with 5438 patients assigned to clopidogrel or aspirin after PCI
- Patients completed dual antiplatelet therapy for 6-18 months before assignment
- Median follow-up duration of 10.5 years, with primary endpoint assessment of all-cause death, MI, stroke, ACS readmission, and bleeding.
- Clopidogrel group had a primary composite endpoint rate of 25.4% compared to 28.5% for aspirin (HR 0.86, 95% CI 0.77-0.96, log-rank p=0.0050)
- Thrombotic endpoint occurred in 17.3% of clopidogrel vs 20.0% in aspirin (log-rank p=0.0024)
- Bleeding complications were 9.1% for clopidogrel vs 10.8% for aspirin (log-rank p=0.020).
Study Design
Type
RCT (n=5,438)
Structured PICO
Does clopidogrel reduce the composite of all-cause death, non-fatal myocardial infarction, stroke, readmission due to acute coronary syndrome, and BARC type ≥3 bleeding compared to aspirin in patients who completed event-free dual antiplatelet therapy for 6-18 months after PCI?
P
Population
n=5,438 patients who had completed dual antiplatelet therapy without clinical events for 6-18 months after percutaneous coronary intervention (PCI)
I
Intervention
Clopidogrel 75 mg once daily
C
Comparator
Aspirin 100 mg once daily
O
Outcome
Composite of all-cause death, non-fatal myocardial infarction, stroke, readmission due to acute coronary syndrome, and Bleeding Academic Research Consortium type ≥3 bleedingcomposite
Main Result
Effect estimate: HR 0.86 (95% CI 0.77-0.96)
Absolute Event Rate: 25.4% vs 28.5%
p-value: p=0.0050
Over a 10-year follow-up, clopidogrel monotherapy was superior to aspirin monotherapy in reducing the composite of ischemic and bleeding events during the chronic maintenance phase after PCI.
Cite This Study
Kang et al. (2026) conducted an RCT in Post-percutaneous coronary intervention (PCI) (n=5,438). Clopidogrel vs. Aspirin 100 mg once daily was evaluated on Composite of all-cause death, non-fatal myocardial infarction, stroke, readmission due to acute coronary syndrome, and Bleeding Academic Research Consortium type ≥3 bleeding (HR 0.86, 95% CI 0.77-0.96, p=0.0050). Over 10 years post-PCI, clopidogrel monotherapy significantly reduced the primary composite endpoint compared to aspirin (25.4% vs 28.5%; HR 0.86; 95% CI 0.77-0.96; p=0.0050).