Aspirin remains a cornerstone of antiplatelet therapy in the immediate post-PCI period.
The guideline recommends an initial oral loading dose of 325 mg non–enteric-coated aspirin at the time of PCI, followed by daily low-dose aspirin (75–100 mg) for maintenance in all patients not previously on aspirin.
This approach is supported by robust evidence demonstrating aspirin’s efficacy in reducing death and major adverse cardiovascular events (MACE) after PCI, both in acute coronary syndromes (ACS) and stable coronary disease.
Guidelines now recognize that indefinite aspirin therapy may not be necessary for all patients. In selected patients, particularly those at high bleeding risk or those requiring concomitant oral anticoagulation, discontinuation of aspirin after 1 to 3 months post-PCI, with continuation of P2Y12 inhibitor monotherapy, is now considered appropriate to reduce bleeding risk.
For patients on full-dose anticoagulation, aspirin may be discontinued after 1 to 4 weeks, with continued use of a P2Y12 inhibitor.
The early aspirin discontinuation reduces bleeding without increasing ischemic events in most populations.
The standard duration of dual antiplatelet therapy (DAPT) is at least 6 months for stable coronary artery disease and at least 12 months for ACS, provided there is no excessive bleeding risk.
After completion of DAPT, indefinite low-dose aspirin monotherapy has been the traditional approach, but recent evidence supports the use of P2Y12 inhibitor monotherapy as an alternative, particularly in patients with aspirin intolerance or high bleeding risk.
Recent randomized controlled trials and meta-analyses have provided quantitative data on the safety and efficacy of discontinuing aspirin after PCI, both in the short-term, early discontinuation, and long-term as maintenance monotherapy.
Multiple large-scale trials and meta-analyses have evaluated the impact of early aspirin discontinuation (typically 1–3 months post-PCI) with continuation of P2Y12 inhibitor monotherapy.
The TWILIGHT trial, which randomized patients post-PCI to ticagrelor monotherapy versus continued DAPT after an initial 3-month period, demonstrated a significant reduction in major bleeding with ticagrelor monotherapy, without an increase in ischemic events such as myocardial infarction or stent thrombosis.
A meta-analysis of 13 randomized clinical trials including 53,421 patients found that short DAPT (1–3 months) followed by P2Y12 inhibitor monotherapy significantly decreased net adverse clinical events (NACE).
The reduction in NACE was primarily driven by a decrease in major bleeding events, with no significant difference in mortality, myocardial infarction, stroke, or stent thrombosis.
The TARGET-FIRST trial, evaluated early discontinuation of aspirin (at 1 month) in low-risk patients with acute myocardial infarction who underwent complete revascularization with contemporary drug-eluting stents.
P2Y12 inhibitor monotherapy was noninferior to continued DAPT for the composite endpoint of death, MI, stent thrombosis, stroke, or major bleeding at 1 year, and was associated with a 54% reduction in bleeding complications.
The incidence of stent thrombosis and other ischemic events was low, supporting the safety of early aspirin discontinuation in carefully selected low-risk patients.
In contrast, the NEO-MINDSET trial found that immediate discontinuation of aspirin (median 2 days post-PCI) in ACS patients was associated with an increased risk of ischemic events, particularly subacute stent thrombosis, within the first weeks after PCI subacute stent thrombosis occurred in 10 patients assigned to P2Y12 monotherapy versus 2 patients assigned to continued DAPT.
This suggests that a short period of DAPT remains necessary in ACS patients, and very early aspirin withdrawal may increase early ischemic risk.
The most robust long-term data come from the 2025 individual patient data meta-analysis by Giacoppo et al., which included patients from five randomized trials who had undergone PCI and completed the recommended DAPT regimen (median 12 months), then were assigned to either P2Y12 inhibitor monotherapy (clopidogrel or ticagrelor) or aspirin monotherapy.
At a median follow-up of approximately 3.7 years, P2Y12 inhibitor monotherapy was associated with a significantly lower risk of major adverse cardiac and cerebrovascular events (MACCE) compared to aspirin monotherapy.
The decision to discontinue aspirin after PCI isindividualized based on a comprehensive assessment of patient-specific and procedural factors.
The type of stent implanted during PCI is a foundational determinant of antiplatelet therapy duration and the appropriateness of aspirin discontinuation.
New-generation drug-eluting stents (DES) have improved biocompatibility and lower thrombosis risk, allowing for shorter DAPT durations and earlier consideration of aspirin discontinuation in selected patients.
In contrast, bare-metal stents (BMS) require a minimum of 1 month of DAPT, followed by indefinite aspirin monotherapy.
The risk of stent thrombosis is highest in the first 30 days post-PCI, particularly in patients with ACS, complex lesions, or incomplete revascularization.
Procedural factors such as stent underdeployment, small stent diameter, greater stent length, bifurcation stenting, and in-stent restenosis increase the risk of stent thrombosis and may favor longer DAPT duration, thus delaying aspirin discontinuation.
Patients with complex PCI—defined as three vessels treated, three or more stents or lesions, two stent bifurcation lesions, total stent length >60 mm, or chronic total occlusion—derive greater benefit from DAPT durations longer than 6 months, and potentially longer than 12 months, based on meta-analytic data.
Growing emphasis on individualizing therapy to balance ischemic protection against bleeding risk.
Guideline for the management of patients With The Duffy antigen is the primary entry point for the malaria parasites Plasmodium vivax and Plasmodium knowlesi. Individuals with the Duffy-null phenotype are largely resistant to these specific types of malaria.
Aspirin remains a cornerstone of antiplatelet therapy in the immediate post-PCI period of acute coronary syndrome.
The guideline recommends an initial oral loading dose of 325 mg non–enteric-coated aspirin at the time of PCI, followed by daily low-dose aspirin (75–100 mg) for maintenance in all patients not previously on aspirin.
This approach is supported by robust evidence demonstrating aspirin’s efficacy in reducing death and major adverse cardiovascular events (MACE) after PCI, both in acute coronary syndromes (ACS) and stable coronary disease.
Indefinite aspirin therapy may not be necessary for all patients.
In selected patients, particularly those at high bleeding risk or those requiring concomitant oral anticoagulation, discontinuation of aspirin after 1 to 3 months post-PCI, with continuation of P2Y12 inhibitor monotherapy, is now considered appropriate to reduce bleeding risk.
For patients on full-dose anticoagulation, aspirin may be discontinued after 1 to 4 weeks, with continued use of a P2Y12 inhibitor.
The rationale for this shift is grounded in recent clinical trial evidence showing that early aspirin discontinuation reduces bleeding without increasing ischemic events in most populations.
The standard duration of dual antiplatelet therapy (DAPT) is at least 6 months for stable coronary artery disease and at least 12 months for ACS, provided there is no excessive bleeding risk.
After completion of DAPT, indefinite low-dose aspirin monotherapy has been the traditional approach, but recent evidence supports the use of P2Y12 inhibitor monotherapy as an alternative, particularly in patients with aspirin intolerance or high bleeding risk.
Large-scale trials and meta-analyses have evaluated the impact of early aspirin discontinuation (typically 1–3 months post-PCI) with continuation of P2Y12 inhibitor monotherapy.
The TWILIGHT trial, which randomized patients post-PCI to ticagrelor monotherapy versus continued DAPT after an initial 3-month period, demonstrated a significant reduction in major bleeding with ticagrelor monotherapy, without an increase in ischemic events such as myocardial infarction or stent thrombosis.
A meta-analysis of 13 randomized clinical trials including 53,421 patients found that short DAPT (1–3 months) followed by P2Y12 inhibitor monotherapy significantly decreased net adverse clinical events.
The reduction in NACE was primarily driven by a decrease in major bleeding events, with no significant difference in mortality, myocardial infarction, stroke, or stent thrombosis.
The TARGET-FIRST trial evaluated early discontinuation of aspirin (at 1 month) in low-risk patients with acute myocardial infarction who underwent complete revascularization with contemporary drug-eluting stents.
P2Y12 inhibitor monotherapy was noninferior to continued DAPT for the composite endpoint of death, MI, stent thrombosis, stroke, or major bleeding at 1 year, and was associated with a 54% reduction in bleeding complications.
The incidence of stent thrombosis and other ischemic events was low, supporting the safety of early aspirin discontinuation in carefully selected low-risk patients.
In contrast, the NEO-MINDSET trial found that immediate discontinuation of aspirin (median 2 days post-PCI) in ACS patients was associated with an increased risk of ischemic events, particularly subacute stent thrombosis, within the first weeks after PCI (subacute stent thrombosis occurred in 10 patients assigned to P2Y12 monotherapy versus 2 patients assigned to continued DAPT).
This suggests that a short period of DAPT remains necessary in ACS patients, and very early aspirin withdrawal may increase early ischemic risk.
The best long-term data come from the 2025 individual patient data meta-analysis which included 16,117 patients from five randomized trials who had undergone PCI and completed the recommended DAPT regimen (median 12 months), then were assigned to either P2Y12 inhibitor monotherapy (clopidogrel or ticagrelor) or aspirin monotherapy.
At a median follow-up of 1,351 days (approximately 3.7 years), P2Y12 inhibitor monotherapy was associated with a significantly lower risk of major adverse cardiac and cerebrovascular events (MACCE) compared to aspirin monotherapy
There was a sustained reduction in bleeding events with P2Y12 inhibitor monotherapy.
The decision to discontinue aspirin after PCI must be individualized based on a comprehensive assessment of patient-specific and procedural factors.
The type of stent implanted during PCI is a foundational determinant of antiplatelet therapy duration and the appropriateness of aspirin discontinuation.
New-generation drug-eluting stents (DES) have improved biocompatibility and lower thrombosis risk, allowing for shorter DAPT durations and earlier consideration of aspirin discontinuation in selected patients.
In contrast, bare-metal stents (BMS) require a minimum of 1 month of DAPT, followed by indefinite aspirin monotherapy.
The risk of stent thrombosis is highest in the first 30 days post-PCI, particularly in patients with ACS, complex lesions, or incomplete revascularization.
Procedural factors such as stent underdeployment, small stent diameter, greater stent length, bifurcation stenting, and in-stent restenosis increase the risk of stent thrombosis and may favor longer DAPT duration, thus delaying aspirin discontinuation.
Patients with complex PCI—defined as three vessels treated, three or more stents or lesions, two stent bifurcation lesions, total stent length >60 mm, or chronic total occlusion—derive greater benefit from DAPT durations longer than 6 months, and potentially longer than 12 months, based on meta-analytic data.