Why is this study important?

• Long-term antithrombotic strategy to prevent recurrent ischemic events after percutaneous coronary intervention (PCI) is debated.  
• Limited evidence suggests that P2Y12 inhibitor monotherapy after completion of dual antiplatelet therapy (DAPT) may provide superior protection over aspirin.   

What question was this study supposed to answer?

To compare the efficacy and safety of clopidogrel versus aspirin monotherapy after completion of standard DAPT among high-risk patients undergoing PCI with drug-eluting stents (DES). 

What did the study show?

• 5,506 high-risk patients (previous myocardial infarction [MI], diabetes mellitus on medications, or complex coronary disease) were randomized to either clopidogrel or aspirin monotherapy after completion of standard DAPT.   
• Patients needing long-term oral anticoagulants, DAPT for another indication, or contraindications to aspirin or clopidogrel were excluded.  
• At a median follow-up of 2.3 years, clopidogrel monotherapy was associated with a significant reduction in the primary endpoint (composite of all-cause death, MI, or stroke) compared to aspirin monotherapy [4.4% vs. 6.6%, HR 0.71 (0.54- 0.93), p=0.013].  
• There were no significant differences in rates of stent thrombosis, target vessel or lesion revascularizations and bleeding (BARC 2,3,5).  

Key takeaways

• In the SMART-CHOICE 3 trial, randomizing high-risk patients who completed standard DAPT after PCI, a strategy of clopidogrel monotherapy was associated with reduced risk of major adverse cardiovascular events compared to aspirin monotherapy. There was no difference in bleeding. 
• These findings add to the evidence from prior studies (HOST EXAM, GLOBAL LEADERS) in supporting P2Y12 inhibitor over aspirin monotherapy for long-term ischemic protection after PCI.