Written by Peter Liu
Spoon Feed
For patients who have completed appropriate dual-antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI), P2Y12 inhibitors may be superior to aspirin therapy for single-antiplatelet therapy (SAPT).
P2Y12 inhibitor instead of aspirin for SAPT?
First, the bad news; treatment of atherosclerotic diseases (ASCVD; e.g. stroke, CAD, MI, PAD) is becoming more complicated, and aspirin monotherapy is no longer the one-size-fits-all approach. We have previously commented on several superior alternatives to aspirin for noncardioembolic stroke, and clopidogrel over aspirin for post-PCI patients. Secondary prevention of ASCVD is becoming increasingly tailored to individual patient circumstances, with special consideration to competing thrombotic and bleeding risks.
The good news is significant patient benefit with this tailored approach (note the low number needed to treat below). Today’s focus is on patients post-PCI transitioning from DAPT to SAPT. A recent individual patient data meta-analysis of five randomized trials (n=16,117) assessed P2Y12 inhibitor versus aspirin monotherapy post-PCI following DAPT. Over a median 3.7-year follow-up, P2Y12 inhibitors significantly reduced major adverse cardiac (cardiac death or MI) and cerebrovascular events (HR 0.77, 95%CI 0.67–0.89; NNT=46), without a significant increase in major bleeding risk (HR 1.12, 95%CI 0.74–1.70). Myocardial infarction (HR 0.69) and stroke (HR 0.67) were significantly lower with P2Y12 inhibitors, supporting their use for long-term secondary prevention.
This meta-analysis involved a very heterogeneous patient population, including patients with stable CAD vs. MI and patients who had abbreviated 1-month DAPT durations vs. those with more standard 6-18 month DAPT durations. In general, many patients only had 1-month DAPT durations, which is rare in standard practice. However, the results from this meta-analysis should be interpreted in combination with the results of the recent SMART-CHOICE 3 RCT, which also showed that clopidogrel reduced major adverse cardiac and cerebral events in post-PCI patients with more standard DAPT courses. In aggregate, these studies strongly support consideration of P2Y12 inhibition for SAPT over aspirin in most post-PCI patients.
How does this change my practice?
I predict there will be a long period of inertia in real-word practice patterns despite these promising results of P2Y12 superiority over conventional aspirin therapy, just as we are seeing in the case of widespread aspirin in stroke prevention despite evidence for alternative regimens. However, in patients transitioning from DAPT to SAPT, I will consider a P2Y12 inhibitor regimen as a reasonable and possibly superior option to conventional aspirin therapy.
Source
P2Y12 inhibitor or aspirin after percutaneous coronary intervention: individual patient data meta-analysis of randomised clinical trials. BMJ. 2025 Jun 4;389:e082561. doi: 10.1136/bmj-2024-082561. PMID: 40467090
