Weekly Journal Scan: Ischaemic vs bleeding risk early after myocardial infarction—which should we TARGET FIRST?

This comment refers to ‘Early Discontinuation of Aspirin after PCI in Low-Risk Acute Myocardial Infarction’ which was published in the New England Journal of Medicine, https://doi.org/10.1056/NEJMoa2508808. Balancing ischaemic and bleeding risks after PCI remains a clinical challenge. The primary goals of DAPT following PCI are to prevent stent thrombosis and to reduce the risk of recurrent atherothrombotic events, with an acceptable bleeding risk.3 Current ESC guidelines support a default DAPT strategy with low-dose aspirin plus a P2Y12 inhibitor for 12 months in patients with acute coronary syndrome (ACS), irrespective of the adopted revascularization strategy.3 Low-dose aspirin is currently recommended as the antiplatelet agent of choice (Class I, Level of Evidence A), supported by its established life-saving benefits, predictable pharmacokinetics and pharmacodynamics, and low cost.4 Several RCTs and meta-analyses have questioned the universal adoption of this strategy, suggesting that shorter durations of DAPT—particularly in carefully selected low-risk patients—may preserve ischaemic protection while lowering the risk of bleeding.5 This assumption was based on the observation that advances in PCI techniques, stent platforms, antiplatelet agents, and other pharmacological therapies for atherosclerotic cardiovascular (CV) disease have progressively reduced the residual risk of recurrent ischaemic events.4