Clopidogrel beats aspirin after coronary stenting
After the first year following coronary stent treatment, clopidogrel alone lowered heart-related events versus aspirin alone without more major bleeding.
*Open-label randomized trial with blinded outcome review; Level 1b (OCEBM).

Citation

Watanabe H, Morimoto T, Natsuaki M, et al; STOPDAPT-2 ACS investigators. Clopidogrel Versus Aspirin Monotherapy Beyond 1 Year After PCI: The Final 5-Year Results of the STOPDAPT-2 ACS and STOPDAPT-2 Total Cohort. Circ Cardiovasc Interv. 2026;19:e016280. doi:10.1161/CIRCINTERVENTIONS.125.016280.

Background

After coronary stent treatment, long-term single-drug antiplatelet therapy is often continued, but the best choice remains debated. This study compared clopidogrel versus aspirin as the long-term single drug beyond 1 year.

Patients

Adults in Japan who received coronary stents; one trial enrolled only acute coronary syndrome patients. Excluded: need for long-term blood thinners and prior bleeding inside the skull.

Intervention

One month of aspirin plus a second antiplatelet drug, then clopidogrel alone long-term.

Control

Twelve months of two antiplatelet drugs, then aspirin alone long-term.

Outcome

Main outcome: combined heart-related events (heart-related death, heart attack, stroke, or definite clot in the stent) plus major/minor bleeding (trial definitions). Secondary: the heart-related composite and bleeding separately.

Follow-up Period

5 years total; primary comparison used a 1-year landmark (years 1–5).

Results

Population (years 1–5) Outcome Clopidogrel Aspirin Relative effect NNT
Acute coronary syndrome trial (n=2944) Combined main outcome (primary) 6.18% 8.27% Hazard ratio 0.75 (0.57–0.997) 48
Acute coronary syndrome trial (n=2944) Heart-related composite (secondary) 4.73% 6.77% Hazard ratio 0.70 (0.51–0.96) 49
Pooled trials (n=5901) Heart-related composite (secondary) 5.77% 7.73% Hazard ratio 0.74 (0.60–0.91) 51
Pooled trials (n=5901) Heart attack 2.15% 3.23% Hazard ratio 0.66 (0.48–0.92) 93
Pooled trials (n=5901) New narrowing needing treatment outside the original stent area 6.29% 7.93% Hazard ratio 0.80 (0.65–0.98) 61
Analyses were primarily intention-to-treat. Major/minor bleeding rates were similar between groups.

Limitations

Open-label treatment and different antiplatelet strategies during the first year may influence later comparisons. Almost all participants were Japanese and received a specific stent type with very frequent stomach-protecting drug use, limiting generalizability.

Funding

Abbott; funder reported no role in analysis or writing.

Clinical Application

For patients stable 1 year after coronary stenting, consider clopidogrel over aspirin for long-term single therapy, especially in East-Asian populations, without expecting more major bleeding.