Aspirin-free strategy after short-term dual antiplatelet therapy in patients with complex percutaneous coronary intervention: A systematic review and network meta-analysis

Objectives: The transition from short dual antiplatelet therapy (DAPT) to P2Y 12 inhibitor monotherapy has recently gained popularity as a strategy to reduce aspirin-related bleeding while preserving the antithrombotic benefit of DAPT. However, the safety and efficacy of P2Y 12 inhibitor monotherapy after short-term DAPT in patients who received complex percutaneous coronary intervention (PCI) remains uncertain. Methods: The PubMed, EMBASE, Cochrane Library, and Web of Science were searched to identify randomized controlled trials published in any language between January 1980 and June 2023. Only peer-reviewed articles and randomized controlled trials were included. The primary efficacy and safety endpoints were major adverse cardiovascular events and major bleeding. We divided antiplatelet strategies into three categories based on previous clinical trials: P2Y 12 inhibitor monotherapy after 1 or 3 months DAPT, aspirin monotherapy after 3 or 6 months DAPT, and aspirin monotherapy after long-term (≥12 months) DAPT. The network meta-analysis was performed by the frequentist approach (PROSPERO-ID CRD42020192256). Results: Nine studies involving 16,201 patients with complex PCI were included. Within 1 year after complex PCI, the pooled results showed that compared with long-term DAPT, 1 or 3 months DAPT followed by P2Y 12 inhibitor monotherapy could significantly reduce the risk of primary efficacy endpoint (hazard ratio [HR], 0.67; 95% confidence interval [CI]: 0.52–0.87) as well as the risk of all-cause mortality (HR, 0.55; 95% CI, 0.37–0.81), target vessel revascularization (HR, 0.60; 95% CI, 0.45–0.79), and any bleeding events (HR, 0.52; 95% CI, 0.38–0.73). The indirect comparison revealed that P2Y 12 inhibitor monotherapy was correlated with a lower risk of major adverse cardiovascular events (HR, 0.44; 95% CI, 0.27–0.71), myocardial infarction (HR, 0.50; 95% CI, 0.28–0.90), and target vessel revascularization (HR, 0.61; 95% CI, 0.37–0.98) at 12 months compared with aspirin monotherapy after 3 or 6 months DAPT. Beyond 12 months, there were no significant differences in terms of major adverse cardiovascular events among these three antiplatelet treatments, while major bleeding (HR, 0.37; 95% CI, 0.14–0.94) resulted significantly lower, adopting an aspirin monotherapy strategy compared with prolonged DAPT. Conclusion: For patients with complex PCI, early discontinuation of DAPT to P2Y 12 inhibitor monotherapy might be a safer and equally effective strategy compared with aspirin monotherapy after 3 or 6 months or long-term DAPT.