The optimal long-term antiplatelet strategy after percutaneous coronary intervention (PCI) remains uncertain. The HOST-EXAM trial, published in Lancet, evaluated clopidogrel versus aspirin monotherapy in patients who had completed dual antiplatelet therapy (DAPT) without clinical events. This investigator-initiated 10-year extended follow-up assessed long-term outcomes in this population.

Patients who remained event-free for 6–18 months after PCI while on DAPT were randomly assigned to receive clopidogrel 75 mg once daily or aspirin 100 mg once daily. A total of 5,530 patients were enrolled between March 2014 and May 2018, with 5,438 included in the intention-to-treat analysis (aspirin: n=2,728; clopidogrel: n=2,710). Clinical follow-up was completed in 92.8% of participants by May 2025, with a median follow-up duration of 10.5 years.

The primary endpoint was a composite of all-cause death, non-fatal myocardial infarction (MI), stroke, readmission due to acute coronary syndrome (ACS), and Bleeding Academic Research Consortium (BARC) type ≥3 bleeding.

Clopidogrel was associated with lower rates of the primary composite endpoint compared with aspirin (25.4% vs 28.5%; hazard ratio [HR] 0.86; 95% confidence interval [CI] 0.77-0.96; P=0.0050). Thrombotic events were also lower (17.3% vs 20.0%; P=0.0024), as were bleeding events (9.1% vs 10.8%; P=0.020). All-cause mortality was similar between groups.

These findings indicate lower long-term composite, thrombotic, and bleeding event rates with clopidogrel monotherapy compared with aspirin after PCI, with no difference in all-cause mortality.