Cardiology
META ANALYSIS
● Meta-analysis
Early Aspirin Withdrawal Post-PCI Reduces Bleeding, No MI Increase with P2Y12 Monotherapy
PLoS medicine
Published March 27, 2026
Navarese Eliano P, Gurbel Paul, Tantry Udaya, Talanas Giuseppe, Grzelakowska Klaudyna, Umińska Julia…
PubMed ↗
DOI ↗
This meta-analysis evaluated the safety and efficacy of early aspirin withdrawal compared to continued dual antiplatelet therapy (DAPT) in high-risk patients after percutaneous coronary intervention (PCI). The study included seven randomized trials with a total of 27,743 participants. The primary endpoints were myocardial infarction (MI) and clinically relevant bleeding. Results indicated that transitioning to P2Y12-inhibitor monotherapy (ticagrelor or prasugrel) within three months reduced bleeding (HR=0.55, 95% CI [0.42, 0.71]; p<0.001) without significantly increasing the risk of MI (HR=1.11, 95% CI [0.91, 1.35]; p=0.31), death, stroke, or stent thrombosis. Immediate aspirin noninitiation or in-hospital cessation increased MI risk (HR=1.41, 95% CI [1.01, 1.97]; p=0.04), while early post-discharge discontinuation did not (HR=0.97, 95% CI [0.76, 1.24]; p=0.82). Trial sequential analysis confirmed the conclusiveness of bleeding reduction and the futility of MI excess. Bayesian analysis suggested that in patients at high bleeding risk, discontinuing aspirin within one month provided a 100% probability of bleeding benefit (NNT=12) and a 70% probability of MI safety. For those at high ischemic risk, a three-month discontinuation offered a 100% probability of bleeding benefit (NNT=57) and an 86% probability of MI safety. Limitations included reliance on aggregate data and limited precision in the immediate aspirin withdrawal subgroup. Clinicians should tailor aspirin discontinuation timing to individual bleeding and ischemic risk profiles.
AI Accuracy Review: 8/10
· Auto-published
This study focuses on patients who have had a procedure called percutaneous coronary intervention (PCI) to open blocked arteries in the heart. Researchers looked at different trials to see if stopping aspirin early (within three months) could help reduce the risk of bleeding while still protecting against heart attacks. They found that for patients taking other medications called ticagrelor or prasugrel, stopping aspirin early can significantly lower the chance of bleeding without increasing the risk of heart attacks. This is good news for patients at high risk of bleeding. However, it is important to avoid stopping aspirin right away after the procedure, as this could lead to more heart attacks. Each patient's situation is unique, so doctors should tailor the timing of aspirin withdrawal based on individual bleeding and heart attack risks. While the findings are promising, more research is needed to confirm these results and understand the best approach for different patients.
What this means for you: For some heart patients, stopping aspirin early can reduce bleeding risks without raising heart attack chances.
View Original Abstract ↓
BACKGROUND: Patients at high ischemic or bleeding risk after percutaneous coronary intervention (PCI) require protection against thrombotic events with dual antiplatelet therapy (DAPT) while avoiding bleeding. Although guidelines recommend 12-month DAPT after acute coronary syndrome (ACS), recent trials have tested the safety of early aspirin withdrawal with potent P2Y12-inhibitor monotherapy.
METHODS AND FINDINGS: We performed a meta-analysis of randomized trials (from inception through August 2025) comparing early aspirin withdrawal (≤3 months) with transition to ticagrelor- or prasugrel-monotherapy versus continued DAPT. Co-primary outcomes were myocardial infarction (MI) and clinically relevant bleeding. Prespecified timing analyses stratified the comparison versus DAPT by aspirin timing: immediate (aspirin noninitiation or in-hospital cessation) and early (post-discharge discontinuation within 3 months). Bayesian models quantified risk-stratified probabilities of benefit and harm; trial sequential analysis (TSA) assessed conclusiveness of evidence. Seven trials (n = 27,743) were included. P2Y12-inhibitor monotherapy reduced bleeding (HR = 0.55, 95% CI [0.42, 0.71]; p < 0.001) without significantly increasing MI overall (HR = 1.11, 95% CI [0.91, 1.35]; p = 0.31), death, stroke, or stent thrombosis. Immediate aspirin noninitiation/cessation increased MI (HR = 1.41, 95% CI [1.01, 1.97]; p = 0.04), whereas early discontinuation did not (HR = 0.97, 95% CI [0.76, 1.24]; p = 0.82). TSA indicated conclusiveness for bleeding benefit and futility for an MI excess. Analyses restricted to ACS confirmed the overall results. Bayesian analyses corroborated these effects and identified risk-aligned timing: in high bleeding risk, ≤1-month aspirin discontinuation yielded a 100% posterior probability of bleeding benefit (NNT = 12) and 70% probability of MI-safety; in high ischemic risk, 3-month aspirin discontinuation yielded 100% probability of bleeding benefit (NNT = 57) and 86% probability of MI-safety. Limitations include aggregate data only and limited precision for the immediate aspirin withdrawal subgroup.
CONCLUSIONS: Among high-risk post-PCI patients on ticagrelor/prasugrel, discontinuing aspirin within 3 months reduces bleeding without an ischemic trade-off versus DAPT. Immediate aspirin noninitiation or cessation should be avoided; timing should be individualized to bleeding and ischemic risk. PROSPERO: CRD420251167706.