When less is no longer more: very early aspirin discontinuation after ACS

In patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI), the management of antiplatelet therapy poses two equally important challenges: preventing recurrent ischaemic complications and avoiding bleeding. Importantly, both events can have a similar impact on patients’ prognosis.1 Refinements in stent technology and the adoption of potent P2Y12 receptor inhibitors (P2Y12i) have fostered an unprecedented research effort exploring a wide range of antithrombotic strategies, with de-escalation from dual antiplatelet therapy (DAPT) to P2Y12i monotherapy being the most extensively studied intervention. Collectively, randomised evidence shows that withdrawing aspirin after 1-3 months following PCI is safe in terms of bleeding without a trade-off in ischaemic events.2 Nevertheless, only the NEO-MINDSET trial has evaluated aspirin discontinuation as early as within the first 4 days of hospitalisation for ACS in an adequately powered study. Although P2Y12i monotherapy decreased the risk of bleeding, it failed to meet non-inferiority to DAPT for ischaemic outcomes and was associated with an excess of stent thrombosis.3 This issue may become particularly relevant in patients undergoing complex PCI, in whom the likelihood of ischaemic manifestation...