Aspirin discontinuation after ACS: timing the transition to ticagrelor monotherapy

The optimisation of antiplatelet therapy after acute coronary syndromes (ACS) has evolved substantially in recent years, driven by the dual need to reduce thrombotic risk while minimising bleeding12. Although 12 months of dual antiplatelet therapy (DAPT) remains the conventional strategy used in most patients, accumulating evidence indicates that aspirin can be discontinued earlier when effective P2Y12 inhibition is maintained – an approach for which the strongest evidence derives from trials of ticagrelor monotherapy after 1-3 months of DAPT3. European guidelines have adopted this evidence with a conservative interpretation, issuing a Class IIa, Level of Evidence (LoE) A recommendation for P2Y12 inhibitor monotherapy after 3-6 months of DAPT in selected ACS patients not at high ischaemic risk, without specifying a preferred agent, despite notable differences in the supporting data for each P2Y12 inhibitor1. In contrast, the American guidelines have taken a more evidence-aligned position, assigning a Class I, LoE A recommendation to abbreviated DAPT (1-3 months) followed by ticagrelor monotherapy after percutaneous coronary intervention (PCI)2. Although this recommendation more accurately reflects contemporary evidence, the optimal timing...