People at risk for later cardiac events Percutaneous coronary intervention (PCI) Stent procedure for receiving long-term antiplatelet therapy Clopidogrel 29% less likely to die than those who received it aspirinaccording to data from the Smart-Choice 3 trial. Results showed that patients were also less likely to experience a heart attack, or stroke.
Current clinical guidelines The joint publications by the American School of Cardiology (ACC), the American Heart Association and the Association of Cardiovascular Angiography Interventions have long suggested that patients should take both aspirin and P2Y12 inhibitors.
“In our study, clopidogrel defeated aspirin as a lifetime maintenance monotherapy after standard-phase dual antiplatelet therapy,” said Jooyong Hahn, an interventional psychologist at Samsung Medical Center in Seoul, South Korea, who presented the results of Smart Chassey 3 at ACCINCERIF Session 2025 in Chicago. It’s also published in Rancet.
“Based on these results, we hope that the guidelines will address clopidogrel monotherapy as preferred over aspirin monotherapy in patients that are comparable to aspirin monotherapy or at high risk for recurrent ischemic events,” Hahn said.
Smart-Choice 3 Trial
Smart-Choice 3 evaluated 5,500 patients who had undergone PCI in Korea and had a higher risk of future ischemic events due to a history of heart attacks, medication-treated diabetes, or complex coronary lesions. After completing dual antiplatelet therapy, half of the patients were randomly assigned to continue with clopidogrel and half of them continued with aspirin.
2. After a median of 3 years, patients in the clopidogrel group died or experienced heart attack or stroke (4.4% vs. 6.6%) than in the aspirin group. The majority of the differences were caused by a significant reduction in the number of heart attacks in the clopidogrel group (1.0% vs. 2.2%). There was a strong tendency to support clopidogrel in mortality, but there was no significant difference in stroke rates. Furthermore, there was no significant difference in the number of major bleeding events between the two groups.
“In general, more potent antiplatelet therapy increases the risk of bleeding, but in our study, clopidogrel reduced the ischemic endpoint compared to aspirin, but does not increase the risk of bleeding, making it a very ideal outcome,” Hahn said.
The study adds to the discussion of the benefits of aspirin to clopidogrel for long-term antiplatelet therapy, according to Akshay Khandelwal, director of cardiovascular medicine at the AHN Cardiovascular Institute in Detroit, Michigan.
Khandelwal quickly admitted that more than 80% of study participants were male. This raises concerns about the generalizability of the data. “It’s important to understand how this applies to women,” he said, as women tend to bleed more easily than men.
However, this study is conducted exclusively with clopidogrel, which may underestimate the benefits of clopidogrel.
This study was funded by pharmaceutical company Dong-A St Co, Ltd.
