Early Aspirin Discontinuation vs 12-Month Dual Antiplatelet Therapy after Percutaneous Coronary Intervention for Acute Coronary Syndrome: A Meta-Analysis of Randomized Trials.

Background

In patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS), 12-month dual antiplatelet therapy (DAPT) has long been the standard of care. However, emerging evidence suggests that discontinuing aspirin early while maintaining P2Y12 inhibitor monotherapy may reduce bleeding without compromising ischemic protection. We performed a systematic review and meta-analysis to evaluate the impact of early aspirin discontinuation compared with standard 12-month DAPT on clinical outcomes after PCI for ACS.

Methods

A meta-analysis was performed including randomized clinical trials and post-hoc analyses of randomized trials comparing early aspirin discontinuation (within 1-3 months post-PCI) to standard 12-month DAPT in ACS populations. The major endpoints were a composite of net adverse clinical events (NACE), major adverse cardiovascular events (MACE), all cause and cardiovascular mortality, MI, stroke, stent thrombosis (ST), target vessel revascularization (TVR), and bleeding. A random-effects model was used to calculate pooled odds ratios (ORs) with 95% confidence intervals (CIs). Heterogeneity was assessed using I² statistics.

Results

Nine studies were included, encompassing 31,505 patients (15,700 early discontinuation; 15,805 standard DAPT). Across the 9 included studies, early aspirin discontinuation was associated with a significant reduction in NACE compared with standard DAPT (OR 0.77, 95% CI 0.65-0.91; p = 0.002) due to reduction in BARC ≥2 bleeding [0.41; 0.32-0.52; P <0.00001]. Early aspirin discontinuation, compared to 12-month DAPT resulted in similar risk of MACE [0.88; 0.73-1.07; P =0.19], all-cause mortality [0.84; 0.69-1.03; P= 0.09], cardiovascular mortality [1.02; 0.74-1.41; P = 0.92], MI [0.98; 0.77-1.25; P=0.87], stroke [0.97; 0.73-1.29; P =0.82], ST [1.29; 0.83-2.0; P=0.26] and TVR [1.00; 0.79-1.27; P = 1.00].

Conclusion

In ACS patients treated with PCI, early discontinuation of aspirin while maintaining P2Y12 inhibitor monotherapy appears to reduce adverse clinical events compared with standard 12-month DAPT. These findings show net benefit of following early aspirin discontinuation strategy due to reduction in major bleeding events without jeopardizing ischemic outcomes.