Upfront Aspirin-Free Antiplatelet Monotherapy After Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis of Safety and Efficacy

Evidence comparing non-aspirin single antiplatelet therapy (SAPT) with aspirin-containing dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) is limited. We performed a systematic review and meta-analysis to evaluate the safety and efficacy of non-aspirin SAPT with a P2Y12​ inhibitor started at or within one week of PCI. Electronic databases were searched for studies evaluating non-aspirin SAPT after PCI. Primary outcomes were bleeding defined by Bleeding Academic Research Consortium (BARC) criteria BARC 1–5 (any bleeding) and BARC 3–5 (major bleeding), all-cause mortality (ACM), and cardiovascular mortality. Secondary outcomes were stroke, myocardial infarction (MI), need for revascularization, and stent thrombosis (STS). Seven studies (2 randomized controlled trials and 5 observational studies) including 5468 patients on non-aspirin SAPT were analysed. In the single-arm meta-analysis of non-aspirin SAPT, pooled prevalence was 5% (95% CI 3–11;I 2 =92%) for any BARC 1–5 bleeding, 3% (95% CI 1–7;I 2 =92.5%) for major BARC 3–5 bleeding, 2% (95% CI 1–3;I 2 =65.4%) for ACM, 2% (95% CI 2–3;I 2 =31%) for cardiovascular mortality, 1% (95% CI 1–1;I 2 =0%) for STS, 1% (95% CI 0–1;I 2 =40.1%) for stroke, 2% (95% CI 1–3;I 2 =66.6%) for MI, and 2% (95% CI 1–4;I 2 =75.9%) for revascularization. In pairwise analyses of the two trials, non-aspirin SAPT versus aspirin-based DAPT showed similar risks of all-cause mortality, cardiovascular mortality, bleeding, and stroke but higher risks of MI (odds ratio OR1.41;95% CI 1.01–1.97; P=0.05; I 2 =0%) and revascularization (OR1.73; 95% CI 1.18–2.52;P=0.005;I 2 =0%). Upfront aspirin-free SAPT after PCI was associated with increased risks of MI and revascularization without a reduction in bleeding compared with aspirin-based DAPT.