Key result
De-escalation to P2Y12-inhibitor monotherapy after PCI in ACS reduced net adverse clinical events compared to DAPT (5.1% vs. 6.7%; RR 0.75; 95% CI 0.65-0.86), mainly by lowering bleeding.
Why the study?
In patients with ACS undergoing PCI, de-escalation to P2Y12-inhibitor monotherapy reduces bleeding, but the optimal timing of aspirin withdrawal is uncertain.
Does P2Y12-inhibitor monotherapy after aspirin discontinuation reduce net adverse clinical events and bleeding compared to 12-month DAPT in patients with ACS undergoing PCI?
Meta-Analysis (n=33,292)
Does P2Y12-inhibitor monotherapy after aspirin discontinuation reduce net adverse clinical events and bleeding compared to 12-month DAPT in patients with ACS undergoing PCI?
Answers are grounded in this paper and cite their sources.
De-escalation to P2Y12 inhibitor monotherapy after PCI in ACS reduces NACE and bleeding, with 3-month aspirin discontinuation ranking most favorable, while discontinuation at <1 month may increase mortality.
In patients with ACS undergoing PCI, de-escalation to P2Y12-inhibitor monotherapy reduces bleeding, but the optimal timing of aspirin withdrawal is uncertain. We conducted pairwise and network meta-analyses of randomized trials comparing P2Y12-inhibitor monotherapy after aspirin discontinuation versus dual antiplatelet therapy (DAPT) in ACS post-PCI. Random-effects models were used. The network meta-analysis (NMA) compared four strategies (12-month DAPT [central comparator]; aspirin stop < 1 month, 1–2 months, or 3 months) and ranked treatments using SUCRA. (PROSPERO ID: CRD420251151605). A total of 33,292 participants from 10 RCTs were included. In the pairwise meta-analysis, monotherapy reduced net adverse clinical events (NACE) (5.1% vs. 6.7%; RR: 0.75; 95% CI: 0.65–0.86) and bleeding, including clinically relevant bleeding (RR: 0.45; 95% CI: 0.39–0.53) and major bleeding (RR: 0.47; 95% CI: 0.37–0.60). In the NMA, aspirin discontinuation at 3 months showed a trend toward lower NACE versus 12-month DAPT (RR 0.66; 95% CI 0.42–1.04) and ranked most favorable for net and ischemic outcomes (NACE, MI, MACCE, and all-cause mortality), although estimates for individual ischemic endpoints were imprecise and not statistically different from 12-month DAPT. Aspirin discontinuation at < 1 month showed an unfavorable mortality ranking, with a concordant meta-regression signal suggesting higher mortality with earlier aspirin withdrawal. De-escalation to P2Y₁₂ inhibitor monotherapy after PCI in ACS reduced NACE, mainly by lowering bleeding. In network analyses, aspirin discontinuation at 3 months ranked most favorable for net and ischemic outcomes, whereas discontinuation at < 1 month showed an unfavorable mortality signal.
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Shubietah et al. (2026) conducted a meta-analysis in ACS post-PCI (n=33,292). P2Y12-inhibitor monotherapy after aspirin discontinuation vs. Dual antiplatelet therapy (DAPT) was evaluated on Net adverse clinical events (NACE) (RR 0.75, 95% CI 0.65-0.86). De-escalation to P2Y12-inhibitor monotherapy after PCI in ACS reduced net adverse clinical events compared to DAPT (5.1% vs. 6.7%; RR 0.75; 95% CI 0.65-0.86), mainly by lowering bleeding.
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