Low-dose prasugrel versus clopidogrel for dual antiplatelet therapy after percutaneous coronary intervention: insights from the STOPDAPT-2 total cohort

Dual antiplatelet therapy (DAPT) with low-dose prasugrel (3.75 mg daily) is widely implemented after percutaneous coronary intervention (PCI) in Japan. However, the efficacy compared with clopidogrel-based DAPT has not been fully examined in large-scale research. STOPDAPT-2 Total Cohort enrolled 5,997 patients who underwent PCI without major in-hospital complications. Among them, 2,547 patients received prasugrel-based DAPT and 3,402 patients received clopidogrel-based DAPT at discharge within 30 days after index PCI. After propensity score matching, 2,163 patients in each group were compared with respect to 30-day clinical outcomes. The primary outcome was a composite of cardiovascular events (cardiovascular death, myocardial infarction, stent thrombosis, or any stroke) and bleeding events (Thrombolysis in Myocardial Infarction [TIMI] major or minor). The two major secondary outcomes were these cardiovascular composite events and bleeding events. In the landmark analysis, there was no significant difference in the cumulative incidence of the primary outcome between the prasugrel group and the clopidogrel group at 30 days beyond hospital discharge (0.34% and 0.29%, HR 1.17, 95% CI 0.39-3.48, P=0.78). Similarly, no significant differences were observed in cardiovascular events (0.19% and 0.14%, HR 1.33, 95% CI 0.30-5.96, P=0.71) or bleeding events (0.14% and 0.15%, HR 1.00, 95% CI 0.20-4.97, P=0.99). There was also no significant difference in any clinical outcomes for 30-day incidence from index PCI. In conclusion, no significant differences were detected in short-term cardiovascular or bleeding outcomes between low-dose prasugrel-based and clopidogrel-based DAPT in patients after PCI without major in-hospital complications.