Ney Carter Borges: The Evolving Role of Aspirin in Coronary Artery Disease
Ney Carter Borges, Member Cardiologist of Global Physician Association at Cleveland Clinic Florida, shared a post on LinkedIn about a recent article by Mattia Galli et al, published in JACC Journals, adding:
“When Less Is More: Rethinking Aspirin’s Role After Coronary Stenting.
For decades, aspirin was the untouchable cornerstone of antiplatelet therapy in coronary artery disease (CAD).
This JACC state-of-the-art review (Galli et al., 2026) charts a major paradigm shift: as PCI technology and adjunctive therapies have lowered thrombotic complication rates, clinical focus has moved from a ‘thrombosis era’ to a ‘bleeding era’, where minimizing hemorrhagic risk without sacrificing ischemic protection has become the priority.
The authors organize evidence across four clinical settings.
Very early aspirin withdrawal (within days of PCI/ACS) lacks support—NEO-MINDSET and STOPDAPT-3 showed increased ischemic events when aspirin was stopped too soon, confirming it remains essential during the first 30 days.
Withdrawal after 1–3 months of DAPT shows a clear divergence by P2Y12 agent: ticagrelor monotherapy (Twilight, Tico, T-Pass, Ultimate-Dapt, Target-First) consistently cuts major bleeding by over 50 percent without ischemic trade-off, even in non-Asian cohorts—making it the most robustly supported strategy.
Clopidogrel monotherapy in this window is less consistent and warrants caution, ideally guided by platelet function or CYP2C19 testing.
Withdrawal after prolonged DAPT, favoring clopidogrel over aspirin for long-term maintenance (Host-Exam, Smart-Choice 3), shows promise but rests almost entirely on East Asian populations—the so-called ‘East Asian Paradox’—limiting generalizability.
Patients requiring concomitant oral anticoagulation represent the strongest case for aspirin withdrawal: dropping aspirin within 30 days post-PCI, and stopping antiplatelet therapy altogether for long-term OAC maintenance, consistently reduces bleeding without excess thrombotic events.
Current guidelines reflect this evolving consensus unevenly—2025 ACC/AHA recommendations already endorse ticagrelor monotherapy after 1 month (Class I), while ESC guidelines remain more conservative (Class IIb).
Key evidence gaps persist: limited head-to-head comparisons of P2Y12 agents in monotherapy, underused genetic/platelet-function-guided selection, and insufficient data outside East Asian populations.
Bottom line: aspirin withdrawal is safe and beneficial in specific, well-defined windows—but timing, chosen P2Y12 inhibitor, and patient risk profile all matter enormously.”
Title: Aspirin Withdrawal in Patients With Coronary Artery Disease
Authors: Mattia Galli, Davide Capodanno, Jurrien ten Berg, Larisa H. Cavallari, Sunil V. Rao, Pedro A. Lemos, Marco Valgimigli, Mario Gaudino, Adnan Kastrati, P. Gabriel Steg, Renato D. Lopes, C. Michael Gibson, Roxana Mehran, Dominick J. Angiolillo
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