- Design
- Prespecified subgroup analysis of an open-label multicentre RCT (SMART-CHOICE 3)
- Population
- 2,089 patients with diabetes who completed standard DAPT after PCI, Korea
- Primary outcome
- Death from any cause, myocardial infarction or stroke at median 2.3 years
- Effect
- 4.5% vs 9.1%, HR 0.57 (95% CI 0.38–0.86); bleeding 2.9% vs 2.9%
SMART-CHOICE 3 was an open-label Korean randomised trial of clopidogrel versus aspirin monotherapy in 5,506 high-risk patients who had completed standard dual antiplatelet therapy after PCI. This prespecified analysis (published in July 2026) looked at the 2,089 with diabetes.
Over a median 2.3 years, patients with diabetes had more events overall than those without (6.8% vs 4.7%; HR 1.44). Within the diabetes group, the composite of death, MI or stroke occurred in 4.5% on clopidogrel versus 9.1% on aspirin (HR 0.57, 95% CI 0.38–0.86). Bleeding was identical at 2.9% in both arms.
The interaction between diabetes and treatment was not significant (P = 0.124), so the right reading is that clopidogrel was better across the whole trial and people with diabetes, being at higher baseline risk, gain more in absolute terms — not that diabetes is a special indication. The trial was open-label and in an East Asian population, where clopidogrel metabolism differs, though the result points the same way as earlier trials of clopidogrel monotherapy.
For a diabetologist, the relevant moment is the review after DAPT stops: if the cardiology plan says aspirin for life, it is reasonable to ask whether clopidogrel would serve better.
- When dual antiplatelet therapy ends after PCI, ask the cardiology team whether clopidogrel rather than aspirin should be the long-term single agent.
- Absolute benefit is larger in diabetes because baseline risk is higher — about 4.6 fewer events per 100 over 2.3 years in this trial.
- Bleeding did not differ, so there is no safety trade-off on these data.
- Do not stop antiplatelet therapy or switch agents without cardiology input; the decision belongs with the PCI team.
Why it matters
It challenges the reflex of lifelong aspirin after stenting in the highest-risk group diabetologists follow.
Don't overread it
The diabetes result is a subgroup of an open-label trial with no significant interaction — it supports clopidogrel overall, not for diabetes specifically.
The statistics, in plain English
HR 0.57 means the event rate on clopidogrel was a little over half that on aspirin, and the confidence interval (0.38–0.86) stays well below 1. But a P for interaction of 0.124 means the trial could not show that diabetes changes the effect — the benefit is best read as the trial-wide one applied to a higher-risk group.
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