Aspirin Withdrawal Before 30 Days After PCI in Acute Coronary Syndrome and Early Myocardial Infarction Risk: A Systematic Review and Meta-analysis.

BACKGROUND

Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is the standard of care after percutaneous coronary intervention (PCI) in acute coronary syndrome (ACS). Although aspirin discontinuation after at least 1 month of DAPT reduces bleeding without increasing ischemic events, the safety of aspirin withdrawal before the first 30 days after PCI remains uncertain.

METHODS

Online databases were searched through December 2025 to identify randomized controlled trials comparing aspirin-free P2Y12 inhibitor monotherapy initiated within 30 days after PCI versus standard DAPT in ACS patients. Outcomes were assessed during short-term (0-30 days) and longer-term follow-up (31 days to 12 months). Random-effects models were used to estimate odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

Three randomized controlled trials comprising 10,736 patients were included. Within 30 days after PCI, aspirin discontinuation was associated with a higher risk of myocardial infarction (OR, 2.12; 95% CI, 1.31-3.44), without a reduction in bleeding compared with DAPT. No significant differences were observed in other ischemic, composite, or mortality outcomes. During longer-term follow-up, P2Y12 inhibitor monotherapy was associated with significant reductions in bleeding outcomes and net adverse clinical events, without an increase in ischemic outcomes.

CONCLUSIONS

In ACS patients undergoing PCI with drug-eluting stent, aspirin discontinuation within 30 days did not reduce bleeding and was associated with a higher risk of myocardial infarction. These findings suggest the first 30 days after PCI may represent a period of heightened ischemic vulnerability, and routine aspirin withdrawal during this early phase should be interpreted with caution.