Clopidogrel Monotherapy in Older Stable Ischemic Heart Disease Patients Receiving Percutaneous Coronary Intervention: A Paradigm Shift?

As we all age, alterations in our biochemistry and physiology predisposes us to disease states which can affect various pharmacotherapy. In stable ischemic heart disease (SIHD) with percutaneous coronary intervention (PCI), a dynamic balance between ischemic and bleeding risk become paramount as competing events occur over a lifetime. For the longest time, aspirin monotherapy has been the ‘chosen’ antiplatelet therapy for SIHD. Indeed, this has been an effective therapy over time, as demonstrated by the landmark Antiplatelet Trialists’ Collaboration meta-analysis which demonstrated a substantial reduction in vascular events (by about one quarter) with low-dose aspirin 1 Baigent C. Sudlow C. Collins R. Peto R. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ. 2002; 324: 71-86 Crossref PubMed Google Scholar . While this remains true, we must not forget the results of the CAPRIE Trial which was a large multicenter blinded international study of stable atherosclerotic vascular disease patients randomized to clopidogrel or aspirin and found an 8.7% relative risk reduction in the composite of vascular death, myocardial infarction or ischemic stroke in favor of clopidogrel (with numeric reductions in major bleeding events) 2 Gent M. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet. 1996; 348: 1329-1339 Abstract Full Text Full Text PDF PubMed Scopus (6266) Google Scholar . With the evolution of PCI for the treatment of atherosclerotic cardiovascular disease (ASCVD), many different antiplatelet strategies have been recently tested. Moreover, age continues to be an important variable analyzed to ensure consistent treatment effects given competing risks in older patients. Impact of Age on Antiplatelet Monotherapy in the Chronic Maintenance Period After PCI: A Post-hoc Analysis from the HOST-EXAM Extended StudyCanadian Journal of CardiologyPreviewThe HOST-EXAM Extended study reported the benefit of clopidogrel monotherapy over aspirin monotherapy in secondary prevention after percutaneous coronary intervention (PCI). This age-specific subgroup analysis of the study aimed to assess the impact of age on antiplatelet monotherapy after PCI. Full-Text PDF