Stopping Aspirin 3 Months After Stenting Maintains Low Mortality Risk

Joo-Yong Hahn, MD, PhD

Patients undergoing heart surgery to insert a stent can stop taking aspirin after 3 months without increasing their risk of death, according to new research.

The study found that patients who stopped daily aspirin use 3 months after their procedures but continued taking a P2Y₁₂ inhibitor for an entire year had virtually identical outcomes to patients who took both medications for 12 months, which is what current medical guidelines recommend. The combination of aspirin and a P2Y₁₂ inhibitor is known as dual antiplatelet therapy (DAPT).

Lead author Joo-Yong Hahn, MD, PhD, professor of medicine at Sungkyunkwan University School of Medicine, South Korea, said the findings demonstrate that P2Y₁₂ inhibitor monotherapy following 3 months of DAPT is an effective strategy that balances risks of complications without increasing the risk of death.

“Even though this treatment strategy needs to be confirmed in other trials, aspirin may be discontinued in most patients receiving current-generation drug-eluting stents, especially in patients with bleeding risk or in those with stable ischemic heart disease,” he said, in a statement.

Hahn mentioned bleeding risk because, in addition to showing no increased risk of death, patients who stopped aspirin after 3 months also had a significantly lower risk of bleeding.

The study, SMART-CHOICE, enrolled 2993 patients who underwent percutaneous coronary intervention (PCI) procedures to insert drug-eluting stents in 1 of 33 South Korean hospitals. Patients were randomly assigned to a cohort receiving the standard DAPT therapy for 12 months after surgery or a group that stopped aspirin but continued taking the P2Y₁₂ inhibitor after 3 months.

The study’s primary endpoint was a composite of death from any cause, heart attack, or stroke. After a year, 2.9% of patients in the 3-month aspirin group had died, compared to 2.5% among the standard 12-month DAPT group. However, the study also found that 3.4% of patients who took 12 months of DAPT experienced major bleeding. Among the group that quit aspirin at 3 months, the rate of major bleeding was just 2%.

Study participants received 1 of 3 P2Y₁₂ inhibitors: clopidogrel, prasugrel, or ticagrelor. The majority of patients took clopidogrel. Hahn said the fact that all 3 P2Y₁₂ inhibitors were used distinguishes the study from others.

“We believe that the SMART-CHOICE trial, compared with several ongoing trials on P2Y₁₂ inhibitor monotherapy after PCI, provides more generalizable answers to the concept of P2Y₁₂ inhibitor monotherapy across a broad spectrum of patients receiving current-generation drug-eluting stents,” he said.

Hahn said study limitations included the fact that it was open-label, so the patients who stopped taking aspirin early were aware of their cohort status. Another limitation is that some patients in the 3-month group took aspirin after the 3 months had ended. Hahn said he and colleagues analyzed the data in light of that discrepancy and determined that it did not produce a significant enough effect to undermine the findings.

Going forward, Hahn and colleagues say they plan to investigate whether the cessation of DAPT at 3 months had any impact on patients’ risk of ischemic events.

Hahn presented the findings at the American College of Cardiology’s 68th Annual Scientific Session in New Orleans.