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Aspirin Withdrawal in Patients With Coronary Artery Disease
Mattia Galli1, Davide Capodanno2, Jurrien Ten Berg3
1Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy; Maria Cecilia Hospital, GVM Care and Research, Cotignola, Italy.
Insights
Aspirin withdrawal after dual antiplatelet therapy (DAPT) may reduce bleeding in coronary artery disease (CAD) patients. Its effectiveness and safety depend on individual patient factors and treatment choices.
Area of Science:
- Cardiovascular Medicine
- Pharmacology
- Clinical Trials
Background:
- Dual antiplatelet therapy (DAPT) with aspirin and P2Y12 inhibitors is standard for acute coronary syndrome (ACS) and percutaneous coronary intervention (PCI).
- DAPT reduces ischemic events but increases bleeding risk, particularly when combined with oral anticoagulation (OAC).
- Aspirin withdrawal after initial DAPT is being explored to mitigate bleeding risk without compromising ischemic protection.
Purpose of the Study:
- To review the pharmacologic basis, clinical evidence, and guidelines for aspirin withdrawal in coronary artery disease (CAD) patients.
- To provide practical guidance on implementing aspirin withdrawal strategies.
- To address considerations for aspirin withdrawal in CAD patients with and without concomitant OAC indications.
Main Methods:
- Literature review of pharmacologic rationale for aspirin withdrawal.
- Analysis of clinical trial data evaluating aspirin withdrawal efficacy and safety.
- Examination of current guideline recommendations for antithrombotic therapy in CAD.
Main Results:
- Aspirin withdrawal shows potential for reducing bleeding complications in select CAD patients.
- Efficacy and safety outcomes are influenced by patient characteristics, clinical context, and alternative antithrombotic choices.
- The optimal timing and regimen for aspirin discontinuation require careful consideration.
Conclusions:
- Aspirin withdrawal is a viable strategy for select CAD patients to balance ischemic and bleeding risks.
- Personalized approaches are necessary, considering patient-specific factors and concomitant OAC use.
- Further research and adherence to guidelines are crucial for safe implementation.
Abstract:
In patients with coronary artery disease (CAD), aspirin has long represented the cornerstone of antiplatelet therapy for secondary prevention. In patients with an acute coronary syndrome (ACS) and undergoing percutaneous coronary intervention (PCI), oral P2Y12 inhibitors have traditionally been used as adjuncts to aspirin, a strategy known as dual antiplatelet therapy (DAPT). Although DAPT reduces the risk of ischemic recurrences, it carries a risk of bleeding. In CAD patients with a concomitant indication for oral anticoagulation (OAC)-who account for approximately 15% of patients--the combination of aspirin and OAC is associated with an increased risk of bleeding without ischemic benefit. The adverse impact of bleeding on prognosis has prompted investigations aimed at identifying antithrombotic treatment regimens associated with reduced bleeding without compromised ischemic protection. Among these, a strategy of aspirin withdrawal after a brief period of combination therapy has emerged as an attractive option. The efficacy and safety of aspirin withdrawal, however, vary substantially according to clinical setting, patient profile (eg, age, sex, ethnicity, genetic background, and comorbidities), timing of discontinuation after ACS or PCI, and alternative adjunctive antithrombotic therapy, including use of OAC and choice of P2Y12 inhibitor. After reviewing the pharmacologic rationale for aspirin withdrawal, the clinical trial evidence, and guideline recommendations, we provide practical considerations for the implementation of this strategy in patients with CAD, with and without an indication to be on OAC.
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