Lancet
Ten-year data challenge aspirin as default after PCI
Clinical takeaway: For stable patients who remain event‑free after completing dual antiplatelet therapy following drug‑eluting stent PCI, consider clopidogrel 75 mg daily—rather than aspirin—as a preferred long‑term single antiplatelet option, given sustained reductions in net adverse outcomes over 10 years.
Long‑term antiplatelet therapy after PCI has traditionally defaulted to lifelong aspirin, despite limited modern evidence. With patients now living decades after stenting, the optimal chronic monotherapy remains clinically pivotal.
In the HOST‑EXAM randomized trial, 5,438 adults who completed 6 to 18 months of dual antiplatelet therapy without ischemic or major bleeding events were assigned to clopidogrel 75 mg or aspirin 100 mg daily. Over a median 10.5‑year follow‑up, clopidogrel was associated with a lower incidence of the composite primary endpoint—all‑cause death, nonfatal MI, stroke, ACS readmission, or major bleeding—than aspirin (25.4% vs. 28.5%; hazard ratio, 0.86).
Benefits were biphasic, encompassing both ischemic and bleeding outcomes. Thrombotic events occurred less often with clopidogrel (17.3% vs. 20.0%), as did any bleeding (9.1% vs. 10.8%). All‑cause mortality was similar between groups. The advantage of clopidogrel accumulated over time, with a decreasing number needed to treat across longer follow‑up, and effects were consistent across most subgroups, including patients with chronic kidney disease.
“These findings suggest clopidogrel should be reconsidered as the default lifelong antiplatelet after PCI,” the investigators write, noting that lower costs and durable benefit make a compelling case to move beyond aspirin in contemporary practice.
Source: Kang J, et al. and HOST-EXAM Investigators. (2026, April 11). Lancet. Aspirin versus clopidogrel for chronic maintenance monotherapy after percutaneous coronary intervention: 10-year follow-up of the HOST-EXAM trial