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Early Aspirin Withdrawal After PCI Shows Promise in Reducing Bleeding risk
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Landmark research suggests that discontinuing aspirin just one week after percutaneous coronary intervention (PCI) for acute coronary syndromes (ACS) does not increase the risk of major adverse cardiovascular events (MACE) and considerably reduces the risk of bleeding. The findings, published ahead of print in the New England Journal of Medicine, are poised to reshape clinical practice regarding antiplatelet therapy.
The TWISTER Trial: A Paradigm Shift
the TWISTER (Testing Whether Interrupting Stent antiplatelet Therapy Is Safe and Effective) trial, a randomized, open-label study conducted across multiple centers, enrolled 720 patients with ACS undergoing PCI. Participants were randomly assigned to either a one-week duration of dual antiplatelet therapy (DAPT) – aspirin plus a P2Y12 inhibitor – or a standard duration of DAPT, typically lasting six to twelve months.
Did You Know? …
Aspirin has been a cornerstone of cardiovascular care for decades, but its continued use beyond the acute phase is increasingly being questioned due to bleeding risks.
Key Findings and Data
The primary outcome, a composite of cardiovascular death, myocardial infarction, stroke, or ischemic stent thrombosis, occurred in 4.5% of patients in the one-week DAPT group and 4.2% in the standard DAPT group - a non-meaningful difference. However, the rate of clinically significant bleeding, the secondary endpoint, was significantly lower in the one-week DAPT group (0.8% vs.2.8%; hazard ratio, 0.28; 95% confidence interval, 0.12 to 0.66; P=0.002).
| Outcome | 1-Week DAPT (%) | Standard DAPT (%) | P-value |
|---|---|---|---|
| MACE | 4.5 | 4.2 | NS |
| Clinically Significant Bleeding | 0.8 | 2.8 | 0.002 |
| All-Cause Mortality | 1.9 | 2.2 | NS |
Researchers noted that the benefits of early aspirin withdrawal appeared consistent across various subgroups, including patients with different ACS presentations and those receiving different P2Y12 inhibitors. These findings suggest that a shorter duration of DAPT, with early aspirin cessation, may be a viable strategy for reducing bleeding risk without compromising ischemic outcomes,
stated a lead investigator of the TWISTER trial.
Implications for clinical Practice
The TWISTER trial challenges the conventional wisdom of prolonged DAPT following PCI. The results support a more individualized approach to antiplatelet therapy, weighing the risks of bleeding against the potential benefits of continued aspirin use.This is particularly relevant for patients at high risk of bleeding, such as those with a history of gastrointestinal bleeding or those taking concomitant anticoagulants.
Pro Tip: Consider a patientS bleeding risk factors when determining the optimal duration of DAPT post-PCI.
“The results of the TWISTER trial are practice-changing and will likely lead to a reevaluation of DAPT guidelines.”
Further research is needed to confirm these findings in larger and more diverse populations. Though, the TWISTER trial provides compelling evidence that early aspirin withdrawal after PCI might potentially be a safe and effective strategy for reducing bleeding risk in patients with ACS.
What are your thoughts on the potential impact of these findings on your clinical practice? How might this influence patient counseling regarding DAPT?
Frequently Asked Questions about Aspirin Withdrawal After PCI
- What is DAPT? Dual antiplatelet therapy (DAPT) involves taking two antiplatelet medications – typically aspirin and a P2Y12 inhibitor – to prevent blood clots after a PCI
