Key result
Clopidogrel monotherapy post-DAPT is prescribed in only ~5% of ACS patients, favoring older, multimorbid cases.
Why the study?
Recent Chronic Coronary Syndromes guidelines upgraded clopidogrel to the same recommendation strength as aspirin for long-term monotherapy after ACS or revascularization, prompting evaluation of real-world temporal trends and predictors of aspirin versus clopidogrel monotherapy after DAPT.
Cohort (n=28,088)
Yes
In real-world practice following DAPT for PCI-treated ACS, aspirin remains overwhelmingly preferred (95.4%) over clopidogrel (4.6%), with clopidogrel primarily prescribed to older patients with higher comorbidity burdens.
Real-world post-DAPT monotherapy trends may lag guideline updates; leaves open whether recent CCS recommendations have shifted aspirin versus clopidogrel prescribing.
Background: Recent guidelines on Chronic Coronary Syndromes, for long-term monotherapy after acute coronary syndrome (ACS) or revascularization, have upgraded the recommendation for clopidogrel to the same strength as aspirin. We aimed to evaluate temporal trends and predictors of aspirin use compared to clopidogrel monotherapy following dual antiplatelet therapy (DAPT) in light of recent evidence from RCTs. Methods: Between 2016 to 2024, using healthcare databases of Lombardy, we conducted a real-world study identifying patients aged ≥40 years with PCI-treated ACS treated with clopidogrel or aspirin following DAPT. After DAPT, the trend of prescribing patterns of clopidogrel or aspirin monotherapy was evaluated. Multivariable logistic regression analysis was performed to investigate the association between patients’ clinical profiles and the likelihood of receiving either treatment. Results: Among 28,088 patients, 4.6% (1279) received clopidogrel and 95.4% (26,809) aspirin as monotherapy. This prevalence remained substantially stable over time. Patients receiving clopidogrel were older (71.5 vs. 65.3), had a greater burden of comorbidities, and were more frequently exposed to concomitant medications for cardiovascular prevention (all p value < 0.001). Older age, history of vascular events, diabetes mellitus, and gastro-intestinal disorders were significantly predictive of the choice of clopidogrel monotherapy, while being male sex was associated with the probability of receiving aspirin. Conclusions: Despite emerging evidence favoring clopidogrel over aspirin, the latter continues to be widely used after DAPT. Paradoxically, clopidogrel is primarily preferred for older and more severely ill patients, suggesting that it may be likely perceived as an option in this subgroup population. Further studies are needed to evaluate changes in clinical approach in response to the latest evidence.
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Fernandez et al. (2026) conducted a cohort in PCI-treated Acute Coronary Syndrome (ACS) (n=28,088). Clopidogrel monotherapy following DAPT vs. Aspirin monotherapy following DAPT was evaluated on Prevalence, temporal trends, and clinical predictors of prescribing clopidogrel or aspirin monotherapy following DAPT. Clopidogrel monotherapy after DAPT was prescribed in only 4.6% of PCI-treated ACS patients compared with 95.4% receiving aspirin, predominantly in older patients with more comorbidities (p<0.001).
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