Daily Cardiology Research Analysis

BACKGROUND: Aspirin monotherapy is recommended indefinitely for patients with established coronary artery disease (CAD). The aim of this individual patient level meta-analysis was to provide a comprehensive evaluation of the comparative efficacy and safety of clopidogrel versus aspirin monotherapy in patients with established CAD, most of whom had undergone percutaneous coronary intervention or had acute coronary syndrome. METHODS: We conducted a systematic search in PubMed, Scopus, Web of Science, and Embase to identify randomised trials published from database inception to April 12, 2025, comparing clopidogrel monotherapy with aspirin monotherapy in patients with established CAD who had discontinued or never started dual antiplatelet therapy. Randomised trials featuring an initial phase of dual antiplatelet therapy were eligible for inclusion in this individual patient data meta-analysis. In the main analysis, we used semi-parametric shared log-normal frailty models (one-stage analysis), including a random intercept to account for differences in the baseline hazard across trials, and a random slope to account for between-trial differences in treatment effects. The primary efficacy endpoint was a composite of cardiovascular death, myocardial infarction, or stroke (major adverse cardiovascular or cerebrovascular events [MACCE]); the primary safety endpoint was major bleeding. This study is registered with PROSPERO (CRD42025645594). FINDINGS: Seven randomised trials including 28 982 patients (14 507 assigned to clopidogrel; 14 475 assigned to aspirin) with a median follow-up of 2·3 years (IQR 1·1-4·0) were eligible and included. At 5·5 years, MACCE was less common in patients assigned to clopidogrel than in patients assigned to aspirin (929 events [2·61 per 100 patient-years] vs 1062 events [2·99 per 100 patient-years]; hazard ratio 0·86 [95% CI 0·77-0·96]; p=0·0082). Mortality and major bleeding (256 events [0·71 per 100 patient-years] with clopidogrel vs 279 events [0·77 per 100 patient-years] with aspirin; 0·94 [0·74-1·21]; p=0·64) did not differ. INTERPRETATION: These findings add to the evidence that clopidogrel monotherapy is superior to aspirin monotherapy for MACCE prevention with no increase in the risk of bleeding, and support the preferential use of clopidogrel over aspirin for secondary prevention in patients with established CAD. FUNDING: Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Switzerland.

BACKGROUND: Drug-coated devices are widely used to reduce restenosis after lower limb revascularisation in patients with peripheral artery disease, but their effect on patient-centred outcomes remains unclear. We assessed the effect of paclitaxel-coated devices on clinically important outcomes in patients with intermittent claudication undergoing infrainguinal endovascular revascularisation. METHODS: The Swedish Drug-Elution Trial in Peripheral Arterial Disease 2 (SWEDEPAD 2) was a pragmatic, nationwide, multicentre, participant-masked, registry-based, randomised controlled trial conducted at 22 Swedish vascular centres. Adults 18 years or older with intermittent claudication (Rutherford categories 1-3) undergoing infrainguinal endovascular treatment and with no acute thromboembolic disease of the lower limb or infrainguinal aneurysmal disease were eligible for inclusion. Participants were randomly assigned in a 1:1 ratio after successful guidewire crossing to receive either paclitaxel-coated devices or uncoated balloons or stents. Randomisation was stratified by centre and performed using a computer-generated sequence with allocation concealment via a secure, registry-embedded web system. The primary efficacy endpoint was the between-group difference in quality of life at 1 year, assessed with the six-item Vascular Quality of Life Questionnaire (VascuQoL-6), a peripheral artery disease-specific quality of life instrument. The trial is registered at ClinicalTrials.gov (NCT02051088) and the primary analysis is complete; further analyses are ongoing. FINDINGS: Between Nov 5, 2014, and Sept 27, 2023, a total of 1155 patients were enrolled and randomly assigned across 22 vascular centres in Sweden, of whom 1136 (98·3%) had follow-up data available for analysis. 577 patients were randomly assigned to paclitaxel-coated devices and 578 to uncoated devices, of whom 565 (97·9%) and 571 (98·7%) were included in the intention-to-treat population, respectively. The median age in the analysed cohort was 73·0 years (IQR 68·0-78·0). Of the 1136 patients, 612 (53·9%) were male and 524 (46·1%) were female; and 382 (33·7%) of 1135 had preoperative diabetes (one participant in the paclitaxel-coated device group was missing data). Most patients (677 [59·6%] of 1135) presented with severe claudication (Rutherford category 3). Femoropopliteal interventions were performed in 1092 patients (96·1%). At 1 year, VascuQoL-6 scores did not differ between groups (mean difference -0·02 [95% CI -0·66 to 0·62]; p=0·96). All-cause mortality did not differ over a median 7·1 years (IQR 3·9-8·2); hazard ratio (HR) 1·18 (95% CI 0·94-1·48); p=0·16, although 5-year mortality incidence was higher in patients randomly assigned to the paclitaxel-coated devices group (4·57 vs 3·28 per 100 person-years; HR 1·47 [95% CI 1·09-1·98]; p=0·010). INTERPRETATION: In patients with Rutherford stage 1-3 peripheral artery disease undergoing infrainguinal endovascular revascularisation, paclitaxel-coated devices did not improve disease-specific quality of life at 1 year compared with uncoated devices. All-cause mortality was not different over the total follow-up time, but significantly higher over 5 years. These findings do not support routine use of paclitaxel-coated devices in this patient population. FUNDING: The Swedish Research Council, the Swedish Heart Lung Foundation, the Swedish state under the agreement between the Swedish Government and the county councils.

BACKGROUND: The optimal timing of complete revascularisation for patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease remains unclear. We aimed to assess whether immediate complete revascularisation was non-inferior to staged complete revascularisation during the index admission. METHODS: We conducted an open-label, randomised, non-inferiority trial at 14 hospitals in South Korea. Patients aged 19 years or older with STEMI and multivessel disease who had undergone percutaneous coronary intervention (PCI) for a culprit lesion were randomly assigned 1:1 to immediate complete revascularisation (PCI for non-culprit lesions during the index procedure) or staged complete revascularisation (non-culprit PCI on another day during the index admission). Web-based, permuted-block randomisation (using mixed block sizes of two or four) was implemented at each participating centre to allocate patients. Non-culprit lesions with 50-69% stenosis were evaluated by fractional flow reserve. Study participants and study investigators were aware of treatment allocation, but members of the independent clinical committee reviewing primary and secondary endpoints were masked to treatment allocation. The primary endpoint was a composite of death from any cause, non-fatal myocardial infarction, or any unplanned revascularisation at 1 year in the intention-to-treat population, and the non-inferiority margin was set at a hazard ratio (HR) of 1·42; if the upper boundary of the one-sided 97·5% CI of the HR was less than 1·42, immediate complete revascularisation would be considered non-inferior to staged complete revascularisation. Reported adverse events consisted of procedural complications, other complications during admission, and in-hospital clinical events occurring during the index admission. This trial is registered with the Clinical Research Information Service (KCT0004457) and ClinicalTrials.gov (NCT04626882). Long-term follow-up is ongoing. FINDINGS: Between Dec 30, 2019, and Jan 15, 2024, 994 patients were enrolled and randomly assigned to immediate revascularisation (n=498; immediate group) or staged revascularisation (n=496; staged group). The primary endpoint occurred at 1 year in 65 patients (13%) in the immediate group and 53 patients (11%) in the staged group (HR 1·24 [95% CI 0·86-1·79]; p INTERPRETATION: Among patients with STEMI and multivessel disease, immediate complete revascularisation was not shown to be non-inferior to staged complete revascularisation during the index admission in terms of incidence of a composite of death from any cause, non-fatal myocardial infarction, or any unplanned revascularisation at 1 year. This finding might inform future clinical guidelines on the role and optimal use of immediate complete revascularisation during the index admission. FUNDING: Boston Scientific.