Is Aspirin Still Indispensable After PCI-Rethinking Dual Antiplatelet Therapy in Contemporary Practice

Area of Science:

• Cardiology
• Pharmacology
• Clinical Trials

Background:

• Dual antiplatelet therapy (DAPT) with aspirin has been standard after percutaneous coronary intervention (PCI) for over 20 years.
• Contemporary drug-eluting stents have lower thrombotic risk, potent P2Y12 inhibitors are available, and major bleeding is recognized as a negative outcome predictor.

Purpose of the Study:

• To reassess the optimal duration and composition of antiplatelet therapy post-PCI.
• To synthesize evidence from recent randomized trials and meta-analyses on aspirin withdrawal and P2Y12 monotherapy strategies.

Main Methods:

• Systematic review and synthesis of data from recent randomized controlled trials (e.g., NEO-MINDSET, STOPDAPT-3, T-PASS, TWILIGHT, HOST-EXAM, STOPDAPT-2).
• Inclusion of study-level and individual patient data meta-analyses (e.g., PANTHER).
• Consideration of mechanistic rationale, clinical contexts, and guideline evolution.

Main Results:

• Immediate aspirin-free strategies showed potential excess ischemic events in Acute Coronary Syndrome (ACS) patients.
• One-month and three-month DAPT followed by P2Y12 monotherapy significantly reduced bleeding without increasing ischemic events in selected populations.
• Long-term data suggest clopidogrel monotherapy is superior to aspirin for secondary prevention post-PCI, while ticagrelor/prasugrel offer more reliable protection in the first year, especially in ACS.

Conclusions:

• Antiplatelet therapy post-PCI requires individualization based on patient risk, stent type, and time elapsed.
• Transitioning to P2Y12 monotherapy after an initial DAPT period is effective for reducing bleeding.
• Choice of P2Y12 agent is critical, with clopidogrel monotherapy carrying risks in the first year post-ACS due to pharmacogenomic variability.