Clopidogrel is better than aspirin after coronary stenting in patients with diabetes

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Using clopidogrel as long-term maintenance therapy after dual antiplatelet therapy for coronary stenting resulted in a lower rate of the primary composite end point compared to aspirin monotherapy, regardless of whether the patient had diabetes or not, according to a new study, which concluded that clopidogrel may be a better option than aspirin for these patients.

In this post hoc analysis of the HOST-EXAM randomized clinical trial that enrolled patients who received dual antiplatelet therapy after percutaneous coronary intervention with drug-eluting stents and had no clinical events for 6 to 18 months, all 5438 patients were randomized to receive either clopidogrel or aspirin monotherapy. The main outcome was the primary composite endpoint of death, myocardial infarction, stroke, readmission due to acute coronary syndrome, and major bleeding at 24-month follow-up. Subgroup analyses were conducted based on the presence of diabetes

Among the 5438 patients enrolled in this study, 1860 (34.2%) had diabetes, with 925 receiving clopidogrel and 935 receiving aspirin. Follow-up was completed by 5338 (98.2%) patients.

In those with diabetes, the rate of the primary composite end point was lower in the clopidogrel group compared to the aspirin group (6.3% vs 9.2%; hazard ratio [HR], 0.69; 95% confidence interval [CI], 0.49-0.96; P  =  0.03; absolute risk difference [ARD], 2.7%; number needed to treat [NNT], 37). This result was also observed in patients without diabetes (5.3% vs 7.0%; HR, 0.76; 95% CI, 0.58-1.00; P  =  0.046; ARD, 1.6%, NNT, 63; P for interaction  =  0.65). The presence of diabetes did not affect the benefit observed with clopidogrel monotherapy over aspirin for the thrombotic composite end point (HR, 0.68; 95% CI, 0.45-1.04 for patients with diabetes vs HR, 0.68; 95% CI, 0.49-0.93 for those without; P for interaction  = 0 .99) or for any bleeding with Bleeding Academic Research Consortium 2, 3, or 5 (HR, 0.65; 95% CI, 0.39-1.09 for patients with diabetes vs HR, 0.74; 95% CI, 0.48-1.13 for those without; P for interaction  =  0.71).


Rhee T, Bae J, Park KW, et al. Aspirin vs Clopidogrel for Long-term Maintenance After Coronary Stenting in Patients With Diabetes: A Post Hoc Analysis of the HOST-EXAM Trial. JAMA Cardiol. 2023. doi:10.1001/jamacardio.2023.0592