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Discontinuing Aspirin on Background of P2Y12 Inhibitor After PCI
Quick Takes
- P2Y12 inhibitor monotherapy 1-3 months after PCI is associated with reduced bleeding events and no significant increase in ischemic events compared to DAPT.
- In select patients, it may be safe to discontinue aspirin and continue with P2Y12 inhibitor monotherapy to reduce risk of bleeding post-PCI.
Study Questions:
What is the safety and efficacy of discontinuing aspirin therapy and continuing P2Y12 inhibitor therapy post–percutaneous coronary intervention (PCI)?
Methods:
This was a meta-analysis of five randomized trials which had studied discontinuation of aspirin 1-3 months after PCI with continued P2Y12 inhibitor monotherapy compared to dual antiplatelet therapy (DAPT). Follow-up duration ranged from 12-15 months post-PCI. The primary bleeding and major adverse cardiac event (MACE) outcomes were the prespecified definitions in each trial.
Results:
The study population included 32,145 patients; 14,095 (43.8%) with stable coronary artery disease and 18,046 (56.1%) with acute coronary syndrome (ACS). In the experimental arm, background use of a P2Y12 inhibitor was clopidogrel in 2,649 (16.5%) and prasugrel or ticagrelor in 13,408 (83.5%) patients. In total, 820 patients experienced a primary bleeding outcome and 937 experienced MACE. Discontinuation of aspirin therapy 1-3 months post-PCI significantly reduced the risk of major bleeding by 40% compared to DAPT (1.97% vs. 3.13%; hazard ratio [HR], 0.60; 95% confidence interval [CI], 0.45-0.79), with no observed risk of MACE (2.73% vs. 3.11%; HR, 0.88; 95% CI, 0.77-1.02), myocardial infarction (MI) (1.08% vs. 1.27%; HR, 0.85; 95% CI, 0.69-1.06) or death (1.25% vs. 1.47%; HR, 0.85; 95% CI, 0.70-1.03). Findings were consistent among patients who underwent PCI for an ACS, in whom discontinuation of aspirin after 1-3 months reduced bleeding by 50% (1.78% vs. 3.58%; HR, 0.50; 95% CI, 0.41-0.61) and did not appear to increase the risk of MACE (2.51% vs. 2.98%; HR, 0.85; 95% CI, 0.70-1.03).
Conclusions:
Discontinuation of aspirin with continued P2Y12 inhibitor monotherapy reduces risk of bleeding when stopped 1-3 months after PCI. An increased risk of MACE was not observed following discontinuation of aspirin, including patients with ACS.
Perspective:
Duration of DAPT post-PCI and ACS has evolved from 12 months without compromise to alternative recommendations based on type of clinical presentation, stent used, and patient’s overall bleeding and thrombotic risk. Large randomized controlled trials have studied safety and efficacy of both, early discontinuation of P2Y12 inhibitor and continuing with aspirin monotherapy, and more prolonged (18 months) continuation of DAPT compared to standard 12 months. The current meta-analysis posits another alternative: It is safe to discontinue aspirin 1-3 months post-PCI regardless of type of clinical presentation (ACS vs. stable angina) and regardless of type of P2Y12 inhibitor (clopidogrel vs. ticagrelor vs. prasugrel) being used.
Despite the data presented from this meta-analysis, a one size fits all approach to platelet therapy including P2Y12 monotherapy should be done with caution given the heterogeneity of disease expression and treatment among patients with atherosclerotic cardiovascular disease. The data do, however, provide reassurance about discontinuing aspirin if bleeding is a concern in select patients. There still remain questions about clopidogrel nonresponders, benefit of 12 months of DAPT as part of medical management post-ACS and long-term choice for antiplatelet therapy for secondary prevention of cardiovascular disease.
Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Prevention, Stable Ischemic Heart Disease, Atherosclerotic Disease (CAD/PAD), Interventions and ACS, Interventions and Coronary Artery Disease, Chronic Angina
Keywords: Acute Coronary Syndrome, Angina, Stable, Aspirin, Coronary Artery Disease, Hemorrhage, Myocardial Infarction, Myocardial Ischemia, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Secondary Prevention
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