Potent P2Y

Summary

In a prespecified analysis of 3,410 ACS patients, early aspirin discontinuation with potent P2Y12 inhibitor monotherapy increased 1‑year ischemic events in STEMI (HR 1.60) but not in NSTE‑ACS, while consistently lowering bleeding in both groups. These data support maintaining DAPT early after PCI in STEMI.

Key Findings

• Among STEMI patients, early aspirin-free strategy increased ischemic composite events at 1 year vs DAPT (8.2% vs 5.2%; HR 1.60; 95% CI 1.14–2.24).
• In NSTE-ACS, ischemic outcomes were similar between monotherapy and DAPT (HR 0.84; 95% CI 0.53–1.35; P for interaction=0.030).
• Bleeding was significantly lower with monotherapy in both STEMI (HR 0.37; 95% CI 0.22–0.61) and NSTE-ACS (HR 0.45; 95% CI 0.23–0.86).

Clinical Implications

Avoid very early aspirin withdrawal in STEMI treated with PCI; in NSTE-ACS, P2Y12 monotherapy may be considered to reduce bleeding without excess ischemia, with individualized assessment.

Limitations

• Subgroup analysis may be underpowered for certain interactions and susceptible to residual confounding
• Details on specific P2Y12 agents and timing of aspirin withdrawal are not fully elaborated in the abstract

Future Directions

Randomized trials designed to compare early aspirin discontinuation vs continued DAPT separately in STEMI and NSTE‑ACS, with mechanistic platelet function substudies and high bleeding‑risk cohorts.