Early Aspirin Discontinuation Following PCI for Acute Coronary Syndromes: A Systematic Review and Meta-Analysis of Reconstructed Individual Patient Data

Background: Dual antiplatelet therapy (DAPT) is well-established for patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI).Contemporary studies demonstrated that a shorter DAPT strategy may reduce bleeding, while preserving ischemic protection.However, optimal timing of aspirin discontinuation remains uncertain. Methods:We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing standard 12-month DAPT versus early aspirin discontinuation (1-2 months), following PCI for ACS, excluding studies with immediate aspirin withdrawal.We systematically searched PubMed, Embase, and Cochrane.Individual patient data were reconstructed from Kaplan-Meier (KM) curves.Hazard ratios (HRs) and their 95% confidence intervals (CIs) were estimated using Cox regression.All statistical analyses were performed using R version 4.5.0. Results:We included 5 RCTs comprising 12,984 patients; 6,473 (49.8%) were randomized to early aspirin discontinuation.Short-term DAPT was associated with a reduction in the risk of bleeding (HR 0.44; 95% CI 0.34 -0.55; P<0.001), while preserving ischemic protection, with no differences in the risk of MACE (HR 1.05; 95% CI 0.83 -1.32; P=0.71).Stratified bleeding analyses demonstrated a reduction in major bleeding (HR 0.40; 95% CI 0.26-0.61;P<0.01) and a reduction in clinically relevant bleeding (HR 0.43; 95% CI 0.34-0.55;P<0.001). Conclusion:In trials evaluating aspirin discontinuation at approximately 1 month following PCI for ACS, transitioning to P2Y12i monotherapy reduced bleeding while preserving ischemic protection in selected patients.