P2Y12 inhibitor monotherapy after abbreviated dual antiplatelet therapy following percutaneous coronary intervention: a meta-analysis

BACKGROUND AND AIMS: After percutaneous coronary intervention (PCI), growing evidence supports P2Y12 inhibitor monotherapy after a short course of dual antiplatelet therapy (DAPT) as a safer and equally effective antiplatelet strategy compared with continued DAPT. However, the optimal timing of aspirin discontinuation remains uncertain. METHODS: A systematic review and meta-analysis of randomized controlled trials investigating different timings of aspirin discontinuation after a short course of DAPT in PCI patients, compared with continued DAPT, was conducted. Pairwise random-effects and network meta-analyses were performed. The primary endpoint was major adverse cardiovascular events (MACE). Secondary endpoints included major bleeding, major or minor bleeding, net adverse cardiovascular events (NACE), all-cause death and myocardial infarction. The study was registered in PROSPERO (CRD420251140207). RESULTS: Eleven randomized trials including 37,443 patients were identified. In pairwise analyses, compared with 12-month DAPT, there were no significant differences in the risk of MACE with aspirin discontinuation at either ≤1 month (risk ratio [RR] 1.01; 95% confidence interval [CI] 0.85-1.20) or 3 months (RR 0.95; 95% CI 0.67-1.36), with no significant differences between discontinuation timings. Both major and major or minor bleeding were significantly reduced with ≤1-month (RR 0.46; 95% CI 0.23-0.94; P = 0.038 and RR 0.43; 95% CI 0.36-0.51; P < 0.001, respectively) and 3-month (RR 0.59; 95% CI 0.39-0.89; P = 0.027 and RR 0.57; 95% CI 0.53-0.60; P = 0.005, respectively) discontinuation, with a more pronounced reduction in major or minor bleeding with ≤1-month discontinuation (P = 0.044 for interaction). NACE was significantly reduced with ≤1-month discontinuation, and no significant differences between discontinuation timings emerged. Network meta-analyses yielded consistent results, and for major or minor bleeding, the indirect comparison showed superiority of ≤1-month over 3-month aspirin discontinuation (RR, 0.75; 95% CI, 0.57-0.99; P = 0.044). In a sensitivity analysis restricted to acute coronary syndromes, early aspirin discontinuation was associated with a higher risk of stent thrombosis (RR 1.81; 95% CI 1.15-2.84; P = 0.019), with the excess risk observed mainly with very early aspirin discontinuation (