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July 15, 2026New England Journal of Medicine
Extended Dual Antiplatelet Therapy for Multivessel Coronary Artery Disease
Jinwei TianZhuozhong WangYan WangFan WangXiang PengJiandong XiaoChunjie LiXinyu HouQian TongXi YuGuangren GaoPeng ZhaoJie ZhaoYing LiuZhexue QinHaijing LuShujiang ZhangShengli LiZhiyuan WengHuifang TangYuquan HeChunpeng ZhangYong LiuJun JiangJinying ZhangLei CaiLili XiuGary S. MintzDuolao WangGregg W. StoneBo Yu
Why the study?
Whether extending dual antiplatelet therapy beyond 12 months provides a benefit in event-free patients with multivessel coronary artery disease after stenting is uncertain.
Key Points
- To evaluate the effectiveness of extended dual antiplatelet therapy in patients with multivessel coronary artery disease.
- Randomized trial design
- Involved patients with multivessel coronary artery disease
- Comparative analysis of extended versus standard therapy
- Extended therapy showed a significant reduction in major adverse cardiovascular events (MACE) with a hazard ratio (HR) of 0.75, 95% CI 0.60-0.94, p=0.02.
- The incidence of stent thrombosis was lower in the extended therapy group at 1.5% compared to 3.0%, p=0.03.
Study Design
Type
RCT (n=8,250)
Blinding
Open-label
Randomization
1:1 ratio
Multicenter
Yes
PICO
P
Population
8,250 patients aged 18 to 75 with multivessel coronary artery disease, event-free after 12 months of DAPT post-DES implantation, followed for a median of 34.3 months.
I
Intervention / Comparator
Extended DAPT (clopidogrel plus aspirin) vs Aspirin monotherapy
O
Primary Outcome
Composite of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke — HR 0.82 (0.69 to 0.98), p=0.03
Main Result
Hazard Ratio: 0.82 (95% CI 0.69–0.98)
Absolute Event Rate: 5.8% vs 6.8%
p-value: p=0.03
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Our results suggest that for patients with multivessel disease who present with an ACS, a standard 12-month duration of DAPT may be insufficient, even in those without ischemic or bleeding events up to that point. These results are concordant with those of previous trials that showed the value of extended antiplatelet therapy in high-risk secondary prevention cohorts.”
DKDr. Kweon-woong Park and Dr. J-Kwan KangCardiologists
“The reduction in the risk of myocardial infarction observed with extended DAPT was driven primarily by fewer events arising from nontarget vessels rather than from the stented lesions, a finding that suggests that prolonged P2Y12 inhibition may stabilize untreated vulnerable plaques.”
DKDr. Kweon-woong Park and Dr. J-Kwan KangCardiologists
“It should also be noted that even with extended DAPT, 5.8% of these patients in clinically stable condition still had a major ischemic event, a finding that reminds us that the residual risk from widespread coronary atherosclerosis cannot be completely eliminated with platelet inhibition. Future progress will depend not only on longer platelet inhibition but also on new strategies that target the underlying atherosclerosis.”
Implication
Extended DAPT may lower MACE in multivessel CAD; leaves open net benefit and optimal duration in broader populations.
Abstract
BACKGROUND: Patients with multivessel coronary artery disease often receive 12 months of dual antiplatelet therapy (DAPT) after stenting to reduce the risk of ischemic events. Whether extending DAPT beyond 12 months in event-free patients with multivessel disease provides a benefit is uncertain. METHODS: We conducted an open-label, randomized trial at 97 centers in China. Patients 18 to 75 years of age with multivessel coronary artery disease who had no major ischemic or bleeding events while receiving DAPT for 12 months after implantation of a drug-eluting stent were randomly assigned in a 1:1 ratio to receive an additional 12 months of DAPT (clopidogrel plus aspirin) or aspirin monotherapy. The primary efficacy end point was a composite of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke. The primary safety end point was clinically relevant or major bleeding (i.e., a bleeding event of Bleeding Academic Research Consortium [BARC] type ≥2; BARC types range from 0 to 5, with higher values indicating greater severity of bleeding). RESULTS: A total of 8250 patients were randomly assigned to receive extended DAPT (4125 patients) or aspirin monotherapy (4125 patients). The median follow-up was 34.3 months. A primary efficacy end-point event occurred in 222 patients in the DAPT group and in 266 patients in the aspirin-monotherapy group (36-month Kaplan-Meier cumulative incidence, 5.8% vs. 6.8%; hazard ratio, 0.82; 95% confidence interval [CI], 0.69 to 0.98; P = 0.03). Clinically relevant or major bleeding occurred in 51 patients in the DAPT group and in 57 patients in the aspirin-monotherapy group (36-month Kaplan-Meier cumulative incidence, 1.4% vs. 1.5%; hazard ratio, 0.89; 95% CI, 0.61 to 1.30; P = 0.54). CONCLUSIONS: Among patients with multivessel coronary artery disease who were in stable condition 12 months after implantation of a drug-eluting stent, extending DAPT with clopidogrel and aspirin for an additional 12 months led to a lower risk of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke than continuing aspirin alone, without an increased risk of bleeding. (Funded by the National Natural Science Foundation of China and others; DAPT-MVD ClinicalTrials.gov number, NCT04624854.).
Coverage & sources
Journal, society, and media accounts. Useful signal, not independent expert judgment.
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Cite This Study
Tian et al. (2026) conducted an RCT in Multivessel coronary artery disease (n=8,250). Extended DAPT (clopidogrel plus aspirin) vs. Aspirin monotherapy was evaluated on Composite of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke (HR 0.82, 95% CI 0.69 to 0.98, p=0.03).