Efficacy and Safety of Clopidogrel Versus Aspirin Monotherapy After Percutaneous Coronary Intervention: A Systematic Review and Meta-analysis.

Abstract

Background: Coronary artery disease (CAD) is the leading cause of death worldwide. After percutaneous coronary intervention (PCI), dual antiplatelet therapy (DAPT) is recommended to reduce thrombotic events. This meta-analysis assesses the effectiveness of clopidogrel compared to aspirin monotherapy following DAPT post-PCI.

Methods: From inception to April 2025, an exhaustive literature search was conducted across electronic databases, including PubMed, Cochrane Library, ScienceDirect, EMBASE, and Web of Science. Risk ratios (RRs) along with 95% confidence intervals (CIs) were pooled using the random-effects model in Review Manager. Leave-one-out sensitivity analysis and funnel plots were used to evaluate heterogeneity and publication bias, respectively.

Results: Six studies, including 3 RCTs and 3 observational studies, spanning over 19 494 patients, were included in our analysis. Clopidogrel significantly reduced major adverse cardiovascular events (MACE) (RR = 0.78; 95% CI: [0.69, 0.89]; P = .0002; I ² = 0%) and myocardial infarction (MI) (RR = 0.73; 95% CI: [0.56, 0.94]; P = .02; I ² = 21%) compared to aspirin. Likewise, the clopidogrel group demonstrated a substantial advantage in reducing the incidence of any stroke (RR = 0.66; 95% CI: [0.49, 0.89]; P = .006; I ² = 14%), including ischemic stroke (RR = 0.69; 95% CI: [0.49, 0.97]; P = .04; I ² = 0%). All other endpoints, including hemorrhagic stroke, all-cause mortality, cardiac death, major bleeding, stent thrombosis, repeat, and target vessel revascularization, were comparable between the 2 arms.

Conclusion: Clopidogrel significantly reduced the incidence of MACE, MI, and stroke after DAPT following PCI compared to aspirin, indicating greater effectiveness. However, the main conclusion of this meta-analysis depends primarily on the estimates from RCTs. Additional randomized studies are necessary to confirm these results and support clinical decision-making.