Early Aspirin Discontinuation After Coronary Stenting: A Systematic Review and Meta-Analysis

Abstract

Background 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.

Keywords: aspirin; coronary artery disease; meta‐analysis; stent.

Figure 1. PRISMA flow chart for the trial selection process.

ACS indicates acute coronary syndrome; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta‐Analyses; and RCTs, randomized controlled trials.

Figure 2. Summary of risk estimates for primary outcomes with early aspirin discontinuation vs dual antiplatelet therapy after coronary stenting.

Plot of hazard ratio for all‐cause death (A) and myocardial infarction (B) associated with early aspirin discontinuation (experimental therapy) vs dual antiplatelet therapy (control therapy). The diamonds indicate the point estimate and the left and the right ends of the lines indicate the 95%CIs. Official titles and acronyms: AUGUSTUS: Aspirin Placebo in Patients with Atrial Fibrillation and Acute Coronary Syndrome or Percutaneous Coronary Intervention; WOEST: What is the Optimal Antiplatelet and Anticoagulant Therapy in Patients with Oral Anticoagulation and Coronary Stenting; GLOBAL LEADERS: Comparative Effectiveness of 1 Month of Ticagrelor Plus Aspirin Followed by Ticagrelor Monotherapy Versus a Current‐day Intensive Dual Antiplatelet Therapy in All‐comers Patients Undergoing Percutaneous Coronary Intervention With Bivalirudin and BioMatrix Family Drug‐eluting Stent Use; SMART CHOICE: Comparison Between P2Y12 Antagonist Monotherapy and Dual Antiplatelet Therapy in Patients Undergoing Implantation of Coronary Drug‐Eluting Stents; STOP DAPT 2: Short and Optimal Duration of Dual Antiplatelet Therapy‐2 Study; TICO: Ticagrelor Monotherapy After 3 Months in the Patients Treated With New Generation Sirolimus Stent for Acute Coronary Syndrome; TWILIGHT: Ticagrelor With Aspirin or Alone in High‐Risk Patients After Coronary Intervention. OAC indicates oral anticoagulation; and PCI, percutaneous coronary intervention.

Figure 3. Summary of risk estimates for secondary outcomes with early aspirin discontinuation vs dual antiplatelet therapy after coronary stenting.

Plot of hazard ratio for stent thrombosis (A), stroke (B), and major bleeding (C) associated with early aspirin discontinuation (experimental therapy) vs dual antiplatelet therapy (control therapy). The diamonds indicate the point estimate and the left and the right ends of the lines indicate the 95% CIs. Official titles and acronyms: AUGUSTUS: Aspirin Placebo in Patients with Atrial Fibrillation and Acute Coronary Syndrome or Percutaneous Coronary Intervention; WOEST: What is the Optimal Antiplatelet and Anticoagulant Therapy in Patients with Oral Anticoagulation and Coronary Stenting; GLOBAL LEADERS: Comparative Effectiveness of 1 Month of Ticagrelor Plus Aspirin Followed by Ticagrelor Monotherapy Versus a Current‐day Intensive Dual Antiplatelet Therapy in All‐comers Patients Undergoing Percutaneous Coronary Intervention With Bivalirudin and BioMatrix Family Drug‐eluting Stent Use; SMART CHOICE: Comparison Between P2Y12 Antagonist Monotherapy and Dual Antiplatelet Therapy in Patients Undergoing Implantation of Coronary Drug‐Eluting Stents; STOP DAPT 2: Short and Optimal Duration of Dual Antiplatelet Therapy‐2 Study; TICO: Ticagrelor Monotherapy After 3 Months in the Patients Treated With New Generation Sirolimus Stent for Acute Coronary Syndrome; TWILIGHT: Ticagrelor With Aspirin or Alone in High‐Risk Patients After Coronary Intervention. OAC indicates oral anticoagulation; and PCI, percutaneous coronary intervention.