Evidence gap
The answer is genuinely unknown — a pending outcome trial will settle it.
Resolves via: Resolving-trial readout
Cut aspirin too soon and high-risk patients throw clots; keep it too long and they bleed — this decides the default regimen for nearly everyone leaving the cath lab after ACS.
Active since Sep 2019
The debate
13 clinicians quoted on the record
Pulling aspirin at 1-3 months and running P2Y12 monotherapy cuts bleeding without a clear ischemic penalty, so the old 12-month dual regimen overtreats most patients.
“Recent evidence suggests that withdrawal of aspirin after 1 to 3 months of DAPT, followed by P2Y12 inhibitor monotherapy may reduce bleeding while preventing recurrent ischaemic events compared with 12 months of DAPT.”
“In high-risk PCI patients, further ischemic events remain a life-threatening concern. As seen in TWILIGHT, in patients who tolerated three months of dual antiplatelet therapy, lowering the risk of major bleeding while preserving the ischemic benefit using ticagrelor monotherapy i”
+ 3 more on this side
Until adequately powered trials pin down exactly who can safely drop aspirin, abandoning the guideline-recommended 12 months risks recurrent thrombosis in patients who still need protection.
“Until adequately powered randomised controlled trials demonstrate a clinically meaningful identification of those patients, we should continue to adhere to the current guideline-recommended 12-month minimum DAPT duration following ACS.”
“Overall, these findings suggest that in acute coronary syndrome patients undergoing PCI, very early aspirin withdrawal does not reduce early bleeding and significantly increases ischemic events at 30 days.”
Where the experts land
5–2 on record · 6 unplaced
De-escalate early · 5
On the record, unplaced · 6
Hold the line · 2
“Abbreviation of DAPT duration after 1–6 months, followed by monotherapy with aspirin or a P2Y12 inhibitor, reduces bleeding without an increase in ischaemic events in patients at high bleeding risk, particularly those without high ischaemic risk.”
Where the field stands
Common ground
Stopping aspirin within the first few days looks too aggressive, especially after STEMI, and shorter dual therapy reliably reduces bleeding.
The crux
Can most ACS patients safely drop aspirin after 1 to 3 months, or should STEMI patients stay on dual therapy longer?
Still unknown
Adequately powered trials that compare short dual-therapy windows separately in STEMI and NSTE-ACS would settle it.
On the record
Their own words — position stated as published
“antiplatelet and anticoagulation trials test earlier withdrawal of aspirin or oral anticoagulants to reduce bleeding risk”
Tomasz Guzik · ESC Congress Program Committee Chair · 2 statements · Cardiovascular Business ↗
aspirin-free after 1 month is possible
“Aspirin-free strategies are possible after 1 month.”
Gilles Montalescot · Interventional cardiologist · 2 statements · MedPage Today ↗
“test earlier withdrawal of aspirin or oral anticoagulants to reduce bleeding risk and simplify treatment”
Professor Tomasz Guzik · ESC spokesperson · ESC ↗
prasugrel default; short DAPT with ticagrelor if de-escalating
“For me Prasugrel is the first choice unless I want to shorten dapt to 1-3/12 then I use ticagrelor and stop aspirin”
Mamas A. Mamas · Professor of Cardiology · X ↗
Where do you land?
No votes yet — the measured split appears at 10.
Where the evidence stands
NEO-MINDSET did not prove early potent P2Y12 monotherapy noninferior to 12-month DAPT for ischemia, with harm concentrated in STEMI (HR 1.60) and less bleeding overall. TARGET FIRST and other short-DAPT trials support de-escalation after 1 month in selected patients. Ultra-short (≤4 days) aspirin withdrawal looks too aggressive in STEMI.
What's settled
4What's still open
4How this gets settled
The answer is genuinely unknown — a pending outcome trial will settle it.
What tips it: Lack of a large-scale randomized trial in an all-comer ACS population, including STEMI patients.
Who could settle it
Know an expert who could settle this? Suggest one →
Who this affects
600K–1M
Who could fund or run it
Institutions that could fund, run, or adopt
Sources & verification
+ 49 more, each dated and verification-tagged
Who we found publicly on the record — a snapshot, not a poll of the field. Larger dots are deciders; dashed dots are scan-reported, not yet verified.