However, the trial data reveal a distinct clinical trade-off, showing that extended dual-drug regimens provide superior protection against major ischemic events.
Evaluating Post-Stent Antiplatelet Strategies in the A-CLOSE Trial
Current clinical guidelines recommend 6 to 12 months of dual antiplatelet therapy (DAPT) following a coronary stent procedure, followed by lifelong single antiplatelet therapy using either aspirin or clopidogrel. Yet, determining the ideal duration of DAPT beyond one year remains challenging for individuals facing a high risk of recurrent heart clots due to complex medical histories or multi-vessel arterial blockages.
To examine this window, researchers conducted the A-CLOSE trial across 19 medical centers in South Korea. The study enrolled 3 203 participants with an average age of 63, of whom 18,4 % were women. All patients had received a drug-eluting stent 12 months prior and presented with at least one high-risk clinical feature—such as diabetes, chronic kidney disease, heart failure, prior stroke, or acute coronary syndrome—or complex lesion characteristics like left main coronary disease or chronic total occlusion. Investigators randomized these participants to receive either clopidogrel monotherapy or continued DAPT for an additional 24 months.
Ischemic Protection Versus Bleeding Risks
At the 24-month mark, the trial demonstrated that both strategies yielded similar overall net adverse clinical events. According to the data, the primary composite endpoint—comprising all-cause death, myocardial infarction, stent thrombosis, stroke, or Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 bleeding—occurred in 5,0 % of the clopidogrel monotherapy group and 5,1 % of the extended DAPT group, meeting criteria for non-inferiority.
Despite the comparable net outcomes, individual safety and efficacy metrics diverged sharply between the two approaches:
- Ischemic Events: Key ischemic events—including all-cause mortality, myocardial infarction, stent thrombosis, or stroke—occurred more frequently in patients receiving clopidogrel monotherapy at 3,7 %, compared to 1,6 % for those on prolonged DAPT.
- Bleeding Events: Conversely, major or clinically relevant bleeding events defined as BARC type 2, 3, or 5 occurred significantly less often with clopidogrel monotherapy at 1,8 %, compared to 4,1 % for the extended DAPT cohort.
Personalizing Long-Term Care After Stent Placement
Trial principal investigator Professor Byeong-Keuk Kim of Severance Cardiovascular Hospital at Yonsei University College of Medicine in Seoul noted that the results highlight a clear clinical compromise for high-risk patients. Prolonged DAPT offers enhanced defense against severe ischemic episodes and death, while clopidogrel monotherapy successfully mitigates bleeding complications.
Because no single strategy fits every patient, medical professionals emphasize that long-term antiplatelet management requires individualization. Clinicians must weigh ischemic and bleeding risks alongside patient clinical characteristics and preferences through shared decision-making.
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