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A Critical Appraisal of Aspirin in Secondary Prevention: Is Less More?
Giuseppe Gargiulo1, Stephan Windecker1, Pascal Vranckx1
1From Department of Cardiology, Bern University Hospital, University of Bern, Switzerland (G.G., S.W., M.V.); Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (G.G.); Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Belgium (P.V.); Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.); The Zena and Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M.); and Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands (M.V.).
Insights
Aspirin has long been standard for preventing cardiovascular events. New research questions this, exploring if P2Y12 inhibitors alone offer a better balance of preventing clots versus bleeding risks.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Trials
Background:
- Aspirin is a cornerstone of antiplatelet therapy for cardiovascular disease secondary prevention.
- Historical data supports aspirin's efficacy, forming current guidelines.
- Dual-antiplatelet therapy (DAPT) with P2Y12 inhibitors and aspirin improves ischemic event prevention but increases bleeding risk.
Purpose of the Study:
- To re-evaluate the established paradigm of aspirin use in atherothrombotic event secondary prevention.
- To explore the potential of P2Y12 inhibitor monotherapy as an alternative to DAPT.
Main Methods:
- Review of historical evidence for aspirin monotherapy.
- Analysis of studies comparing dual-antiplatelet therapy (aspirin plus P2Y12 inhibitor) with aspirin monotherapy.
- Investigation of ongoing trials evaluating P2Y12 inhibitor monotherapy versus DAPT.
Main Results:
- Dual-antiplatelet therapy demonstrates superiority over aspirin monotherapy in preventing ischemic events, albeit with higher bleeding risks.
- Current research is investigating the efficacy and safety of P2Y12 inhibitor monotherapy.
Conclusions:
- The long-standing reliance on aspirin for secondary prevention of atherothrombotic events warrants re-examination.
- Emerging evidence from ongoing trials may justify a "less-is-more" strategy with P2Y12 inhibitors alone.
Abstract:
Aspirin represents the sine qua non for antiplatelet pharmacotherapy in patients with cardiovascular diseases because of its well-established role in secondary prevention and its widespread availability and affordability. Historical studies, conducted in an era that bears little resemblance to contemporary clinical practice, demonstrated large reductions in thrombotic risk when aspirin was compared with placebo, thus forming the evidence base promulgated in practice guidelines and recommendations. P2Y12 inhibitors have mostly been studied in addition to aspirin; dual-antiplatelet therapy proved superiority compared with aspirin monotherapy for the prevention of ischemic events, despite increased bleeding risks. An alternative approach currently under investigation includes evaluation of single-antiplatelet therapy with P2Y12 inhibitors alone versus dual-antiplatelet therapy after acute coronary syndromes or coronary stent implantation. As the availability of more effective antiplatelet agents increases, it is time to revisit the existing and long-standing paradigm supporting aspirin use for secondary prevention of atherothrombotic events. Ongoing trials will provide new evidence whether the less-is-more strategy is justified.
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