Antiplatelet monotherapy decreased bleeding however twin remedy supplied larger cardiovascular occasion safety in sufferers at excessive ischemic threat who had undergone stent implantation 12 months earlier. These outcomes, from the A-CLOSE trial, have been introduced in a Sizzling Line session as we speak at ESC Congress 2026 and have been revealed concurrently within the New England Journal of Medication.
After stent implantation for a blocked coronary artery, present tips suggest 6 to 12 months of DAPT adopted by long-term single antiplatelet remedy with both aspirin or clopidogrel. Nonetheless, some sufferers stay at significantly excessive threat for recurrent coronary heart assaults or blood clots because of underlying medical situations (equivalent to acute coronary illness, diabetes, kidney illness, coronary heart failure or a historical past of stroke) or complicated artery blockages requiring a number of or in depth stents. For these at excessive ischemic threat, the optimum length of DAPT past 12 months stays unsure.
The A-CLOSE trial in contrast two totally different antiplatelet methods in high-risk sufferers who had undergone drug-eluting stent implantation 12 months earlier. Its Principal Investigator, Professor Byeong-Keuk Kim from Severance Cardiovascular Hospital, Yonsei College Faculty of Medication, Seoul, South Korea, defined: “After drug-eluting stent implantation, clinicians should stability safety from ischemic occasions towards the bleeding threat related to extended DAPT. Though clopidogrel monotherapy is more and more used after DAPT, its efficacy and security in contrast instantly with prolonged DAPT has not been examined in sufferers at excessive ischemic threat.”
The A-CLOSE trial was performed in 19 centres in South Korea. Members have been eligible if that they had undergone drug-eluting stent implantation 12 months earlier and had not less than one high-risk medical function (acute coronary syndrome, diabetes, continual kidney illness, coronary heart failure, prior stroke or peripheral artery intervention) or high-risk lesion function (left predominant coronary artery lesion, a bifurcation lesion, continual whole occlusion, multivessel illness or diffuse lengthy lesions). Members have been randomised to clopidogrel monotherapy or prolonged DAPT for twenty-four months.
The research inhabitants embrace 3,203 members who had a imply age of 63 years and 18.4% have been girls.
After 24 months, the 2 methods produced comparable charges of web antagonistic medical occasions. The first endpoint of all-cause loss of life, myocardial infarction, stent thrombosis, stroke or Bleeding Educational Analysis Consortium (BARC) sort 2, 3 or 5 bleeding with clopidogrel monotherapy was noninferior to prolonged DAPT (5.0% vs. 5.1%; p=0.001 for noninferiority).
Of be aware, a key ischemic endpoint occurred extra steadily with clopidogrel monotherapy than with prolonged DAPT (all-cause mortality, myocardial infarction, stent thrombosis or stroke: 3.7% vs. 1.6%; p<0.001). All-cause mortality occurred in 1.3% of sufferers with clopidogrel monotherapy and 0.4% of sufferers with DAPT.
A key bleeding endpoint occurred much less steadily with clopidogrel monotherapy (BARC sort 2, 3 or 5 bleeding: 1.8% vs. 4.1%; p<0.001).
Concluding, Professor Kim famous that the outcomes of the A-CLOSE trial confirmed a transparent trade-off in sufferers at excessive ischemic threat: “Prolonged DAPT supplied larger safety towards main ischemic occasions, together with loss of life, whereas clopidogrel monotherapy decreased main or clinically related bleeding. It appears that evidently no single technique is finest for each affected person, however reasonably, long-term antiplatelet remedy must be individualized in line with ischaemic and bleeding dangers, medical traits and therapy preferences in a shared decision-making course of between sufferers and physicians.“
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