Early Aspirin Discontinuation Following Acute Coronary Syndrome or Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Paul Guedeney,Sabato Sorrentino,Johanne Silvain,Benoit Lattuca,Mathieu Kerneis,Ciro Indolfi,Gilles Montalescot,Jean-Philippe Collet,Jules Mesnier,Michel Zeitouni,Salvatore De Rosa,Farouk Abcha

doi:10.3390/jcm9030680

Abstract

The respective ischemic and bleeding risks of early aspirin discontinuation following an acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI) remain uncertain. We performed a prospero-registered review of randomized controlled trials (RCTs) comparing a P2Y12 inhibitor-based single antiplatelet strategy following early aspirin discontinuation to a strategy of sustained dual antiplatelet therapy (DAPT) in ACS or PCI patients requiring, or not, anticoagulation for another indication (CRD42019139576). We estimated risk ratios (RR) and 95% confidence intervals (CI) using random effect models. We included nine RCTs comprising 40,621 patients. Compared to prolonged DAPT, major bleeding (2.2% vs. 2.8%; RR 0.68; 95% CI: 0.54 to 0.87; p = 0.002; I2: 63%), non-major bleeding (5.0 % vs. 6.1 %; RR: 0.66; 95% CI: 0.47 to 0.94; p = 0.02; I2: 87%) and all bleeding (7.4% vs. 9.9%; RR: 0.65; 95% CI: 0.53 to 0.79; p < 0.0001; I2: 88%) were significantly reduced with early aspirin discontinuation without significant difference for all-cause death (p = 0.60), major adverse cardiac and cerebrovascular events (MACE) (p = 0.60), myocardial infarction (MI) (p = 0.77), definite stent thrombosis (ST) (p = 0.63), and any stroke (p = 0.59). In patients on DAPT after an ACS or a PCI, early aspirin discontinuation prevents bleeding events with no significant adverse effect on the ischemic risk or mortality.

Highlights

The optimal antithrombotic regimen following acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI) has known considerable evolutions over the last thirty years
Compared to prolonged dual antiplatelet therapy (DAPT), major bleeding (2.2% vs. 2.8%; risk ratios (RR) 0.68; 95% confidence intervals (CI): 0.54 to 0.87; p = 0.002; I2: 63%), non-major bleeding (5.0 % vs. 6.1 %; RR: 0.66; 95% CI: 0.47 to 0.94; p = 0.02; I2: 87%) and all bleeding (7.4% vs. 9.9%; RR: 0.65; 95% CI: 0.53 to 0.79; p < 0.0001; I2: 88%) were significantly reduced with early aspirin discontinuation without significant difference for all-cause death (p = 0.60), major adverse cardiac and cerebrovascular events (MACE) (p = 0.60), myocardial infarction (MI) (p = 0.77), definite stent thrombosis (ST) (p = 0.63), and any stroke (p = 0.59)
Current guidelines still recommend the continuation of prolonged DAPT including aspirin and a P2Y12 inhibitor based on ancient pivotal randomized trials [1,2,3]

Summary

Introduction

The optimal antithrombotic regimen following ACS or PCI has known considerable evolutions over the last thirty years. Implementation of newer generation drug-eluting stents (DES), the widespread use of lipid lowering therapy, and a new generation of P2Y12 inhibitors have led to a reduction of ST or non-stent related MI following PCI or ACS [4,5] In these circumstances, the benefit of sustained DAPT may translate into a smaller absolute ischemic event risk reduction, which might be potentially outweighed by the associated higher risk of bleeding [6]. Since aspirin yields limited additional platelet inhibition when associated with P2Y12 inhibitors, aspirin-free strategies have been evaluated in several recent randomized controlled trials enrolling ACS or PCI patients; in some of these studies patients had an indication for chronic oral anticoagulation (OAC) [7,8,9,10,11,12,13,14,15,16,17,18,19]. This systematic review and meta-analysis aims to evaluate the safety and efficacy of early aspirin discontinuation with P2Y12 inhibitors single antiplatelet therapy continuation, as compared with a strategy of sustained DAPT following an ACS or PCI, in patients with or without concomitant OAC treatment

Methods

Results

Conclusion