Efficacy and safety of single antiplatelet therapy with anticoagulation in patients with AMI–cardiogenic shock requiring VA-ECMO

Background Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with stenting is standard of care but increases bleeding risk, particularly in patients requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for acute myocardial infarction–cardiogenic shock. Evidence guiding optimal antithrombotic strategies in this high-risk population remains limited. Methods We conducted a retrospective observational study at a high-volume ECMO center. From January 2018 to December 2022, 351 VA-ECMO patients were screened, and 72 who underwent PCI immediately prior to or during ECMO were included. Patients were grouped by initial post-PCI antiplatelet strategy: aspirin alone (n = 33), augmented therapy (n = 25), or no antiplatelet therapy (n = 14). The primary objective was to evaluate the safety and efficacy of an aspirin-only strategy for preventing in-stent thrombosis. Efficacy was assessed by the incidence of in-stent thrombosis during ECMO hospitalization, and safety was assessed by the occurrence of major bleeding events. Results Groups were similar in age, race, gender, and BMI. No patient developed clinically overt in-stent thrombosis. Major bleeding occurred in 33.3% of aspirin, 48% of augmented, and 50% of no-antiplatelet patients (p = 0.396). Most common bleeding events were hemoptysis, intracranial hemorrhage, and gastrointestinal bleeding. Conclusions Among patients undergoing PCI with concurrent VA-ECMO support, no differences in stent thrombosis or major bleeding were observed between aspirin monotherapy, augmented antiplatelet therapy, or no antiplatelet therapy. However, intracranial hemorrhage occurred more frequently in the Augmented AP group. These findings suggest that aspirin monotherapy may provide adequate protection against stent thrombosis while potentially minimizing bleeding risk in this critically ill population.