Weekly Journal Scan: the NEO-MINDSET of early aspirin discontinuation in patients with acute coronary syndromes is neither justified nor safe

This comment refers to ‘Early Withdrawal of Aspirin after PCI in Acute Coronary Syndromes’ which was published in The New England Journal of Medicine, https://doi.org/10.1056/NEJMoa2507980. Current evidence and clinical guidelines support the use of DAPT, including aspirin and a P2Y12 inhibitor (preferably prasugrel or ticagrelor), for 12 months in patients presenting with ACS, irrespective of the adopted revascularization strategy.2 The primary objectives of DAPT following PCI in these patients are to mitigate the risk of stent thrombosis and to prevent recurrent atherothrombotic events, including MI and stroke. Current guidelines recommend aspirin as the antiplatelet agent of choice (Class I, Level of Evidence A), supported by over three decades of robust scientific data and clinical use, predictable pharmacokinetics and pharmacodynamics.3 Low-dose aspirin is administered to all patients with suspected ACS due to its proven life-saving benefits, based on a mortality trial.4 The ISIS-2 RCT showed that among 17 187 patients with a suspected acute MI, 5-week antiplatelet therapy with low-dose aspirin started within 24 h after the onset of symptoms reduced vascular mortality by 23%, non-fatal reinfarction and non-fatal stroke by 50% and was not associated with any significant increase in cerebral haemorrhage or in bleeds requiring transfusion, as compared with placebo.4 These findings are consistent with a central role of thromboxane A2 (TXA2)-dependent platelet activation in coronary atherothrombosis.5