In patients who completed 6-18 months of event-free DAPT after drug-eluting stent PCI, long-term clopidogrel monotherapy reduced the 10-year composite of death, MI, stroke, ACS readmission, or major bleeding compared with aspirin monotherapy, supporting clopidogrel as a reasonable chronic maintenance alternative to aspirin after PCI.
Study design
- Investigator-initiated, prospective, randomized, open-label trial
- Multicenter trial in South Korea
- 37 sites
- Enrollment: 2014 to 2018
- 1:1 randomization
- N = 5,438
- Median follow-up: 10.5 years
Population
- Age ≥20 years
- Prior PCI with drug-eluting stent
- Completed 6-18 months of DAPT without adverse clinical events
- Mean age 63.5 years
- 25.4% women
- Diabetes: 34%
- Prior MI: 16%
- All patients enrolled in South Korea
Interventions
- Clopidogrel 75 mg daily: 2,710
- Aspirin 100 mg daily: 2,728
- Both used as chronic maintenance antiplatelet monotherapy after DAPT
Primary outcome
- Composite: all-cause death, nonfatal MI, stroke, readmission for ACS, or major bleeding
- 25.4% with clopidogrel vs 28.5% with aspirin at 10 years
- HR 0.86
- P = 0.005
- Clopidogrel superior to aspirin for the primary composite endpoint
Clopidogrel vs Aspirin
Primary composite endpoint at 10 years
25.4% vs 28.5% | HR 0.86
Primary composite: all-cause death, nonfatal MI, stroke, ACS readmission, or major bleeding over 10 years.
Secondary outcomes
- Thrombotic endpoint: 17.3% with clopidogrel vs 20.0% with aspirin
- Thrombotic endpoint included cardiovascular death, ischemic stroke, ACS readmission, and stent thrombosis
- Any bleeding: 9.1% vs 10.8%
- All-cause mortality was similar between groups
- Treatment effect was generally consistent across subgroups
- Potentially greater benefit observed among patients with chronic kidney disease
Safety
- Major bleeding was included in the primary net clinical endpoint
- Any bleeding was lower with clopidogrel than aspirin
- No excess all-cause mortality signal with clopidogrel at 10 years
- Adherence was higher in the clopidogrel arm than the aspirin arm
- Clopidogrel resistance/genotype testing was not routinely assessed
Interpretation
- HOST-EXAM 10-year supports clopidogrel over aspirin for chronic antiplatelet monotherapy after uncomplicated DES PCI and completed DAPT
- The absolute difference was modest but clinically relevant over long-term follow-up
- The benefit was driven by fewer thrombotic events and fewer bleeding events
- This was an East Asian population, so generalizability to broader populations is a key limitation
- Results apply to stable, event-free post-PCI patients, not early post-PCI, active ACS, or patients needing ongoing DAPT or anticoagulation
Kang, J., Chung, J., Park, K. W., et al. (2026). Aspirin versus clopidogrel for chronic maintenance monotherapy after percutaneous coronary intervention: 10-year follow-up of the HOST-EXAM randomized clinical trial. The Lancet. https://doi.org/10.1016/S0140-6736(26)00422-8