Upfront Aspirin-Free Antiplatelet Monotherapy After Percutaneous Coronary Intervention: A Systematic Review and...

Evidence comparing non-aspirin single antiplatelet therapy (SAPT) with aspirin-containing dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) is limited. We performed a systematic review and meta-analysis to evaluate the safety and efficacy of non-aspirin SAPT with a P2Y12​ inhibitor started at or within one week of PCI.

Electronic databases were searched for studies evaluating non-aspirin SAPT after PCI. Primary outcomes were bleeding defined by Bleeding Academic Research Consortium (BARC) criteria [BARC 1-5 (any bleeding) and BARC 3-5 (major bleeding)], all-cause mortality (ACM), and cardiovascular mortality. Secondary outcomes were stroke, myocardial infarction (MI), need for revascularization, and stent thrombosis (STS).

Seven studies (2 randomized controlled trials and 5 observational studies) including 5468 patients on non-aspirin SAPT were analysed. In the single-arm meta-analysis of non-aspirin SAPT, pooled prevalence was 5% (95% CI 3-11;I²=92%) for any BARC 1-5 bleeding, 3% (95% CI 1-7;I²=92.5%) for major BARC 3-5 bleeding, 2% (95% CI 1-3;I²=65.4%) for ACM, 2% (95% CI 2-3;I²=31%) for cardiovascular mortality, 1% (95% CI 1-1;I²=0%) for STS, 1% (95% CI 0-1;I²=40.1%) for stroke, 2% (95% CI 1-3;I²=66.6%) for MI, and 2% (95% CI 1-4;I²=75.9%) for revascularization. In pairwise analyses of the two trials, non-aspirin SAPT versus aspirin-based DAPT showed similar risks of all-cause mortality, cardiovascular mortality, bleeding, and stroke but higher risks of MI (odds ratio [OR]1.41;95% CI 1.01-1.97; P=0.05; I²=0%) and revascularization (OR1.73; 95% CI 1.18-2.52;P=0.005;I²=0%).

Upfront aspirin-free SAPT after PCI was associated with increased risks of MI and revascularization without a reduction in bleeding compared with aspirin-based DAPT.