Monotherapy using clopidogrel or ticagrelor is associated with lower rates of future major adverse cardiac and cerebrovascular events compared with traditional aspirin following percutaneous coronary intervention (PCI), researchers have found.
An analysis of data from five randomised clinical trials involving 16,117 patients with stents showed that after a median 3.7 year follow-up, P2Y12 inhibitor use was associated with a 23% lower risk of cardiovascular death, heart attack or stroke, compared with aspirin.
In addition, there was no significant difference in major bleeding with clopidogrel or ticagrelor compared with aspirin, the team of international researchers reported in the BMJ.
They calculated that one cardiovascular death, heart attack, or stroke would be prevented for every 46 patients taking a P2Y12 inhibitor instead of aspirin after dual therapy.
Taking into account individual outcomes, P2Y12 inhibitor therapy reduced heart attacks and stroke compared with aspirin, but all-cause death, cardiovascular death and stent thrombosis were similar between the treatments, they noted.
Despite some limitations on how the trials were designed, the results were consistent after further analyses accounting for age, sex, geographical region, smoking, previous heart attack or stroke, underlying conditions and medication history, they added.
Challenging the standard of care after PCI
Dual therapy (DAPT) is the standard of care after PCI for one to several months after the stent is inserted. Then, long-term monotherapy with aspirin is recommended irrespective of the number, type, and location of implanted coronary stents.
‘In patients who underwent PCI and had completed DAPT, monotherapy with a P2Y12 inhibitor, consisting of clopidogrel or ticagrelor, compared with aspirin was associated with lower rates of cardiovascular death, myocardial infarction or stroke, owing to lower risk of nonfatal cardiac or cerebrovascular events without an increase in major bleeding,’ the researchers concluded.
A linked editorial from UK experts said the updated study ‘supports preferential P2Y12 inhibitor monotherapy prescription over aspirin’ due to reductions in major adverse cardiac and cerebrovascular events without increasing major bleeding ‘in the medium term’.
But they added: ‘Medium term efficacy does not necessarily extend lifelong, which is the duration we advise patients to continue these medications.’
As such, they recommend the commencement of a large-scale globally representative trial directly comparing different monotherapy strategies, including discontinuation, with extended follow-up.
This ‘would benefit our understanding of the long-term impact of P2Y12 inhibitor monotherapy across the treatment class for secondary prevention following PCI’, they concluded.
A version of this article was originally published by our sister publication Pulse.
