This is a summary of the NEO-MINDSET COMPLEX subanalysis, presented by Dr. Guy Prado at EuroPCR 2026, which evaluated P2Y12 inhibitor monotherapy versus dual antiplatelet therapy (DAPT) after complex percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS).
The study aimed to determine whether anatomical PCI complexity modifies the effects of treatment — aspirin-free monotherapy versus DAPT — on ischemic and bleeding outcomes.
A total of 3,410 ACS patients successfully treated with PCI across 50 centers in Brazil were analyzed. Complex PCI was defined by the presence of at least one of the following criteria: treatment of ≥3 vessels, ≥3 lesions treated, or ≥3 stents implanted; total stent length >60 mm; bifurcation treated with two stents; left main coronary intervention; bypass graft treatment; or chronic total occlusion (CTO).
The analysis showed that PCI complexity did not modify the treatment effect between potent P2Y12 inhibitor monotherapy and DAPT. No significant differences were observed in ischemic events, defined as death, myocardial infarction, stroke, or urgent revascularization.
In the complex PCI group, the incidence of ischemic events was 7.3% with monotherapy versus 5.3% with DAPT.
On the other hand, monotherapy substantially reduced clinically relevant bleeding compared with DAPT, regardless of whether PCI was complex or non-complex (p for interaction = 0.73). In complex cases, bleeding occurred in 2.4% of patients treated with monotherapy versus 5.5% of those treated with DAPT.
Although monotherapy consistently reduced bleeding, no clear net clinical benefit was demonstrated due to the lack of non-inferiority regarding ischemic endpoints.
Conclusions: Early Aspirin Withdrawal May Reduce Bleeding Even in Complex PCI
Anatomical PCI complexity does not appear to be a significant modifier of the effects of P2Y12 inhibitor monotherapy compared with DAPT in patients with acute coronary syndrome. This study provides the first evidence regarding very early aspirin withdrawal in this patient population stratified according to anatomical complexity.
Original Title: P2Y12 Inhibitor Monotherapy vs DAPT After Complex PCI in ACS
Reference: Guy Prado et al EuroPCR 2026.
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