The Official Journal of EuroPCR and the European Association of Percutaneous Coronary Interventions (EAPCI)

Clopidogrel Monotherapy in Patients with and without On-Treatment High Platelet Reactivity: a SMART-CHOICE sub-study

DOI: 10.4244/EIJ-D-21-00223

1. Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; Division of Cardiology, Department of Internal Medicine, Chonnam National Universi
2. Chungbuk Regional Cardiovascular Disease Center, Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, Korea
3. Department of Cardiology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
4. Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
5. Chungnam National University Hospital, Daejeon, Korea
6. Department of Cardiovascular Medicine, Regional Cardiocerebrovascular Center, Wonkwang University Hospital, Iksan, Korea
7. Department of Internal Medicine, Chosun University Hospital, Gwangju, Korea; 8Eulji General Hospital, Seoul, Korea
8. Eulji General Hospital, Seoul, Korea
9. Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Korea, Korea, Republic Of
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Background: Although P2Y12 inhibitor monotherapy has been emerged as a promising alternative for dual antiplatelet therapy (DAPT), there remains concern regarding safety of clopidogrel monotherapy.

Aims: We sought to investigate clinical outcomes of clopidogrel monotherapy in patients with and without on-treatment high platelet reactivity (HPR).

Methods: In the SMART-CHOICE study, 3-month DAPT followed by P2Y12 inhibitor monotherapy was compared with 12-month DAPT undergoing percutaneous coronary intervention. Of these, platelet function test was performed for 833 patients with clopidogrel-based therapy. The primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCE: a composite of all-cause death, myocardial infarction, or stroke) at 12 months.

Results: Overall, 108 (13.0%) patients had HPR on clopidogrel. Patients with HPR had a significantly higher rate of MACCE than patients without HPR (8.7% vs 1.5%, adjusted HR 3.036, 95% CI 1.060-8.693, P=0.038). Treatment effect of clopidogrel monotherapy for the 12-month MACCE was not significantly different compared with DAPT among patients with HPR (8.0% vs. 9.4%, adjusted HR 0.718, 95% CI 0.189-2.737, P=0.628) and without HPR (2.2% vs. 0.9%, adjusted HR 2.587, 95% CI 0.684-9.779, P=0.161; adjusted P for interaction=0.170).

Conclusions: Clopidogrel monotherapy showed treatment effects comparable to DAPT for MACCE in patients with or without HPR. However, HPR was significantly associated with an increased risk of MACCE in clopidogrel-treated patients regardless of maintenance of aspirin.

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