Weekly Journal Scan: is a SMART-CHOICE of clopidogrel monotherapy after coronary stenting supported by adequate evidence?

This comment refers to ‘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’ which was published in The Lancet, https://doi.org/10.1016/S0140-6736(25)00449-0. Antiplatelet therapy is the cornerstone of secondary prevention in patients with chronic coronary syndromes (CCS). For about three decades, single antiplatelet therapy (SAPT) with low-dose aspirin has been the standard of care for the long-term management of CCS.2 Clopidogrel was first tested as an alternative to aspirin in the CAPRIE trial, which enrolled 19 185 patients with three different clinical presentations of atherosclerotic cardiovascular (CV) disease and found a statistically significant heterogeneity in treatment effects.3 Among the 6302 post-myocardial infarction (MI) patients included in the trial, clopidogrel 75 mg daily showed no difference in major adverse CV events (MACE, a composite of ischaemic stroke, MI, or vascular death) vs aspirin 325 mg daily (5.0% vs 4.8%) over 1.9 years, further substantiating aspirin as the preferred SAPT for these patients.3 Three decades later, the SMART-CHOICE 3 trial found clopidogrel superior to low-dose aspirin in reducing MACCE with no difference in bleeding events in East Asian CCS patients who underwent percutaneous coronary intervention (PCI) and an unusually prolonged dual antiplatelet therapy (DAPT).1 These results appear consistent with those of another trial conducted in South Korea, HOST-EXAM (n = 5530).4