P2Y12 Inhibitor Monotherapy vs Aspirin: Results of a Network Meta-Analysis

Revascularization and antiaggregation guidelines have typically recommended aspirin (AAS) as first choice for secondary prevention of cardiovascular events after DES stenting. However, these past few years this strategy has been called into question, seeing as studies have shown the superiority of P2Y12 inhibitor monotherapy (IP2Y12) with clopidogrel or ticagrelor.

Monoterapia Inhibidores P2Y12 vs aspirina: Resultados de un meta-análisis en red

There is little data comparing both monotherapy strategies directly, and only very recent. The aim of this study, conducted by Ando et al, was to compare aspirin vs IP2Y12 after a period of dual antiplatelet therapy (DAPT) after DES stenting via a Network meta-analysis.

It included studies with patients undergoing PCI with second generation stents and was followed up for at least one year. It excluded patients with dual anticoagulation.

Primary efficacy end point was acute myocardial infraction (AMI) and safety end point was major bleeding. Other events looked at were all cause and cardiovascular mortality, stroke, stent thrombosis and BARC 3-5 bleeding.

It included data from 19 studies comparing short DAPT followed by AAS monotherapy vs IP2Y12, vs prolonged DAPT. A total 73126 patients were included: 24075 receiving short DAPT + IP2Y12, 20732 short DAPT + AAS monotherapy, and 28319 receiving prolonged DAPT. Patient age ranged from 61 to 68 years, most were men (70%), and 24 to 39% were diabetic.  

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After using a fixed-effects model, they found that the use of AAS monotherapy was associated to a 32% higher risk of AMI compared against IP2Y12 (RR 1.32, CI 95% 1.08-1.62), with no significant differences in all cause and cardiovascular mortality, stent thrombosis or stroke. 

The number necessary to treat (NNT) of AMI was 261. When looking at both monotherapies, they found reduced risk of bleeding vs. prolonged therapy. However, both clopidogrel and ticagrelor showed anti-ischemic effectiveness, while AAS presented higher AMI rate. 

At sensitivity analysis they found no significative evidence between monotherapies. There were no significant differences between DAPT duration (<6 meses vs >6 meses) as regards outcomes, or subgroup analysis when looking at acute coronary syndrome or multivessel disease. 


IP2Y12 should be considered as an alternative to aspirin monotherapy. These data show 32% increased AMI risk with similar bleeding risk in patients receiving AAS. Also, no differences were found in hard end points such as mortality, stroke or stent thrombosis between single agent platelet inhibitor (SAPT) strategies.  Despite these results, with such high NNT, we should raise the question of the real impact of this change of strategy. 

Dr. Omar Tupayachi

Dr. Omar Tupayachi.
Member of the Editorial Board of SOLACI.org.

Original Title: P2Y12 Inhibitor or Aspirin Following Dual Antiplatelet Therapy After Percutaneous Coronary Intervention.

Reference: Andò, Giuseppe et al. “P2Y12 Inhibitor or Aspirin Following Dual Antiplatelet Therapy After Percutaneous Coronary Intervention: A Network Meta-Analysis.” JACC. Cardiovascular interventions vol. 15,22 (2022): 2239-2249. doi:10.1016/j.jcin.2022.08.009.

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