Welcome to PracticeUpdate! We hope you are enjoying access to a selection of our top-read and most recent articles. Please register today for a free account and gain full access to all of our expert-selected content.
Already Have An Account? Log in Now
Early Aspirin Discontinuation After Coronary Stenting
TAKE-HOME MESSAGE
-
The authors of this meta-analysis of seven randomized trials evaluated outcomes in patients treated a strategy of early aspirin discontinuation or dual antiplatelet therapy (DAPT) following percutaneous coronary intervention with stenting. Over a median of 12 months of follow-up, there was no significant difference in the risk of all-cause death, myocardial infarction, stent thrombosis, or stroke between the two groups. However, the risk of major bleeding was significantly higher in the DAPT group compared with the group assigned to early aspirin discontinuation.
- Although early discontinuation of aspirin after percutaneous coronary intervention and stenting does not impact efficacy, the risk of bleeding is lower with early aspirin discontinuation compared with continued DAPT.
abstract
This abstract is available on the publisher's site.
Access this abstract nowBackground
The clinical impact of early aspirin discontinuation compared with dual antiplatelet therapy (DAPT) in patients undergoing percutaneous coronary intervention with stenting remains poorly studied. We investigated the clinical outcomes of patients assigned to either early aspirin discontinuation or DAPT after percutaneous coronary intervention with stenting.
Methods and Results
We performed a meta-analysis of aggregate data from randomized clinical trials enrolling participants receiving a percutaneous coronary intervention with stenting and assigned to either early aspirin discontinuation or DAPT. Scientific databases were searched from inception through March 30, 2020. Trial-level hazard ratios (HRs) and 95% CIs were pooled using a random effects model with inverse variance weighting. The primary outcome was all-cause death. Secondary outcomes were myocardial infarction, stent thrombosis, stroke, and major bleeding. Overall, 36 206 participants were allocated to either early aspirin discontinuation (experimental therapy, n=18 088) or DAPT (control therapy, n=18 118) in 7 trials. Median follow-up was 12 months. All-cause death occurred in 2.5% of patients assigned to experimental and 2.9% of patients assigned control therapy (hazard ratio [HR], 0.91, 95% CI, 0.75-1.11; P=0.37). Overall, patients treated with experimental versus control therapy showed no significant difference in terms of myocardial infarction (HR, 1.02 [0.85-1.22], P=0.81), stent thrombosis (HR, 1.02 [0.87-1.20], P=0.83), or stroke (HR, 1.01 [0.68-1.49], P=0.96). However, the risk for major bleeding (HR, 0.58 [0.43-0.77], P<0.01) was significantly reduced by experimental as compared with control therapy.
Conclusions
In patients treated with percutaneous coronary intervention and stenting, assigned to a strategy of early aspirin discontinuation versus DAPT, the risk of death and ischemic events is not significantly different but the risk of bleeding is lower.
Additional Info
Early Aspirin Discontinuation After Coronary Stenting: A Systematic Review and Meta-Analysis
J Am Heart Assoc 2021 Jan 07;[EPub Ahead of Print], J Wiebe, G Ndrepepa, S Kufner, AL Lahmann, E Xhepa, C Kuna, F Voll, R Gosetti, KL Laugwitz, M Joner, A Kastrati, S CasseseFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Benign Hematology
Since the 1990s, when studies established dual antiplatelet therapy (DAPT) as the best of several options for the prevention of coronary stent thrombosis, DAPT has been standard of care for patients undergoing coronary stent implantation. Treatment for less than 6 to 12 months without both aspirin and a P2Y12 inhibitor was considered to be blasphemy. However, with more recent attention to the adverse consequences of bleeding, as well as the increasing number of patients who require both antiplatelet therapy post PCI, as well as post ACS, and anticoagulant therapy for conditions such as atrial fibrillation, there has been great interest and investigation into de-escalation of antiplatelet therapy. Recent studies have focused on treating such patient populations with just a short (1- to 3-month) course of DAPT before discontinuing one antiplatelet agent, or even treating immediately post PCI with just a P2Y12 inhibitor (along with an oral anticoagulant). Although most such trials were adequately powered to detect significant differences in bleeding outcomes (which inevitably there were), they were underpowered to exclude significant differences in ischemic outcomes, particularly myocardial infarction and stent thrombosis.
This current meta-analysis of seven trials, including those with and without indications for oral anticoagulants, provides a reasonably powered analyses that demonstrates that no significant differences in ischemic outcomes occurred between those treated with DAPT and those in whom aspirin treatment was either never initiated (in some cases where oral anticoagulant therapy was used) or was discontinued within 1 to 3 months of the procedure. In patients who require both antiplatelet and anticoagulant therapy, data from four major trials, as well as this meta-analysis, provide reassurance that one can discontinue aspirin therapy 1 to 3 months post PCI (or not even initiate aspirin therapy) without a significant risk of increased ischemic events. This strategy has become recommended in guidelines and expert consensus documents, and is increasingly being integrated into everyday practice. For those who do not require oral anticoagulants, current practice is still to, at some time point (usually 6 to 12 months), discontinue the P2Y12 inhibitor in those not at high risk of ischemic events; however, several trials, as well as this meta-analysis, may lead more to drop the aspirin, not the P2Y12 inhibitor.