I'm Joo-Yong Hahn from Samsung Medical Centre, Seoul, South Korea. I'm an Interventional Cardiologist.

What is the main objective of the study?

Aspirin has been recommended as a standard treatment in patients undergoing PCI after the standard duration of dual antiplatelet therapy. However, evidence supporting aspirin is outdated and debated; therefore, clopidogrel monotherapy has been emerging as a promising alternative to aspirin.

So far only one trial, the HOST-EXAM trial, directly compared clopidogrel monotherapy versus aspirin monotherapy in patients undergoing PCI after standard duration of the DAPT. Therefore, another trial with adequate sample size, especially focusing solely on strict endpoints of heart designs, is necessary.

Therefore, we conducted the SMART-CHOICE trial to compare clopidogrel monotherapy versus aspirin monotherapy in patients with high risk of recurrent ischemic events undergoing PCI after the standard duration of DAPT.

What was the study design, patient population and endpoints?

The SMART-CHOICE 3 trial was an investigator-initiated, prospective, randomised, open-label, multicentre trial that was conducted in 26 sites in South Korea. We enrolled patients with high risk of recurrent ischemic events, in other words, prior MI, medication treated diabetes or complex PCI.

Patients who underwent PCI and completed standard duration DAPT were randomly assigned to either receive clopidogrel monotherapy or aspirin monotherapy in a one-to-one fashion. The primary endpoint was a composite of all-cause death, MI or stroke.

What are the key findings?

Between August 2020 and July 2023, 5,506 patients underwent randomisation during a [illegible] follow-up duration of 2.3 years. The cumulative incidence of the primary endpoint was 6.6% in the aspirin group and 4.4% in the clopidogrel group. The difference was statistically significant. The benefit of clopidogrel was mainly due to reduction in myocardial infarction compared with aspirin monotherapy.

There was no significant difference between the two groups in the risk of bleeding. Upper gastrointestinal clinical events occurred less frequently in the clopidogrel monotherapy group compared with the aspirin monotherapy group.

How might these findings influence clinical practice?

The most recent European guideline for the management of chronic coronary syndrome recommend aspirin monotherapy as well as clopidogrel monotherapy as Class 1. However, in real world practise, aspirin is predominantly used.

After the SMART-CHOICE 3 trial, clopidogrel monotherapy should be considered as a first- line therapy, especially when the patients have a high risk of recurrent ischemic events.

What are the next steps for future research?

One of the limitations of our study is that we exclusively enrolled Korean patients; therefore, the results of our study cannot be directly applied to patients from other regions, especially Western countries. So I hope another large, randomised clinical trial will be conducted in Western countries.