Weekly Cardiology Research Analysis
This week produced multiple practice‑shaping cardiology studies: two high‑quality randomized/pooled trials change antithrombotic strategy by favoring clopidogrel over aspirin for long‑term secondary prevention and showing harm from adding aspirin to oral anticoagulation in chronic coronary syndrome. A physiology‑guided revascularization RCT (FFR‑guided complete PCI in NSTEMI) reduced 1‑year events, reinforcing invasive strategy refinement. Across diagnostics and mechanisms, advances included sca
Summary
This week produced multiple practice‑shaping cardiology studies: two high‑quality randomized/pooled trials change antithrombotic strategy by favoring clopidogrel over aspirin for long‑term secondary prevention and showing harm from adding aspirin to oral anticoagulation in chronic coronary syndrome. A physiology‑guided revascularization RCT (FFR‑guided complete PCI in NSTEMI) reduced 1‑year events, reinforcing invasive strategy refinement. Across diagnostics and mechanisms, advances included scalable AI for echocardiographic quantification, novel endothelial and clonal‑haematopoiesis mechanisms linking to blood pressure and atherosclerotic risk, and imaging/techniques that reduce radiation and optimize PCI.
Selected Articles
1. Clopidogrel versus aspirin for secondary prevention of coronary artery disease: a systematic review and individual patient data meta-analysis.
An IPD meta‑analysis of seven randomized trials including 28,982 patients showed clopidogrel monotherapy reduced major adverse cardiovascular or cerebrovascular events (MACCE) versus aspirin (HR 0.86) over long‑term follow‑up without increasing major bleeding or mortality, supporting clopidogrel as the preferred antiplatelet monotherapy after DAPT.
Impact: High‑quality IPD meta‑analysis with large sample and long follow‑up directly challenges entrenched aspirin use and provides strong evidence to change standard secondary prevention practice.
Clinical Implications: Clinicians should consider clopidogrel as the default antiplatelet monotherapy after DAPT in patients with established CAD, particularly post‑PCI or post‑ACS, and adapt guidelines and prescribing practices accordingly.
Key Findings
- MACCE lower with clopidogrel than aspirin (2.61 vs 2.99 events per 100 patient‑years; HR 0.86; p=0.0082).
- Major bleeding rates were similar between clopidogrel and aspirin (HR 0.94; p=0.64).
- Analysis pooled 7 RCTs with 28,982 patients using one‑stage IPD frailty models and extended follow‑up (up to 5.5 years).
2. Aspirin in Patients with Chronic Coronary Syndrome Receiving Oral Anticoagulation.
In a multicenter double‑blind RCT (n=872) of CCS patients on long‑term oral anticoagulation, adding aspirin increased the composite of cardiovascular events, all‑cause mortality, and major bleeding, leading to early trial termination; the results argue against routine aspirin addition to OAC in this population.
Impact: A definitive randomized, double‑blind trial demonstrating harm from a common additive strategy (aspirin + OAC) that will directly inform guideline updates and de‑implementation of a prevalent practice.
Clinical Implications: Avoid routine aspirin addition in patients with chronic coronary syndrome who are receiving long‑term oral anticoagulation; prioritize OAC monotherapy unless there is a compelling short‑term ischemic indication and reassess bleeding risk regularly.
Key Findings
- Primary composite event higher with aspirin: 16.9% vs 12.1% (adjusted HR 1.53; P=0.02).
- All‑cause mortality higher with aspirin: 13.4% vs 8.4% (adjusted HR 1.72; P=0.01).
- Major bleeding markedly higher with aspirin: 10.2% vs 3.4% (adjusted HR 3.35; P<0.001); trial stopped early for excess deaths.
3. Fractional Flow Reserve-Guided Complete vs Culprit-Only Revascularization in Non-ST-Elevation Myocardial Infarction and Multivessel Disease: The SLIM Randomized Clinical Trial.
In a multicenter randomized trial of NSTEMI with multivessel disease (n=478), FFR‑guided complete revascularization reduced the 1‑year composite of death, nonfatal MI, any revascularization, and stroke versus culprit‑only PCI (5.5% vs 13.6%; HR 0.38), primarily by lowering repeat revascularization and net adverse clinical events.
Impact: Provides randomized evidence favoring physiology‑guided complete revascularization in a common clinical scenario (NSTEMI with multivessel disease), informing interventional strategy and heart‑team decision making.
Clinical Implications: When anatomy and patient status permit, consider FFR‑guided treatment of significant nonculprit lesions during index PCI in NSTEMI to reduce 1‑year events—particularly to lower the need for repeat revascularization—while recognizing need for larger trials powered for hard endpoints like death/MI.
Key Findings
- Primary composite at 1 year: 5.5% (complete) vs 13.6% (culprit‑only); HR 0.38; p=0.003.
- Any revascularization reduced: 3.0% vs 11.5%; HR 0.24; p<0.001.
- Net adverse clinical events (NACE) lower with complete revascularization: 6.3% vs 15.3%; HR 0.39; p=0.002.