Delay Aspirin Withdrawal After Stenting

In high-risk stent patients, stopping aspirin after discharge reduced bleeding without more heart attacks.
*Meta-analysis of randomized trials; Level 1a.

Citation

Navarese EP, Gurbel P, Tantry U, et al. PLoS Medicine. 2026;23(3):e1004995. doi:10.1371/journal.pmed.1004995

Background

After coronary stenting, two antiplatelet medicines lower clot risk but increase bleeding. The safest timing for aspirin withdrawal in higher-risk patients has been uncertain.

Patients

27,743 adults in 7 randomized trials after coronary stenting, at high clotting or bleeding risk. Excluded were trials not limited to high-risk patients, clopidogrel-only strategies, nonrandomized designs, confounded medication changes, or nonstandard stents.

Intervention

Aspirin not started or stopped in hospital, or stopped within 3 months, with ticagrelor or prasugrel alone.

Control

Continued aspirin plus ticagrelor or prasugrel.

Outcome

Co-primary outcomes: heart attack and clinically relevant bleeding using the Bleeding Academic Research Consortium scale (0–5).

Follow-up Period

Mostly 12 months; one trial contributed 30-day data.

Results

Significant outcomeComparisonEffectAbsolute impact
Clinically relevant bleedingAspirin stopped ≤3 monthsHazard ratio 0.553.80% vs 6.05%; number needed to treat 45
Major bleedingEarly aspirin withdrawal trialsHazard ratio 0.481.02% vs 2.14%; number needed to treat 90
Heart attackImmediate aspirin nonuse or in-hospital stopHazard ratio 1.41Harm signal

Overall heart attack, death, stroke, and stent clot rates did not significantly differ. Analyses used intention-to-treat trial data. Continued two-drug therapy is current standard for many acute coronary syndrome patients.

Limitations

Used published summary data, not individual patient data. Only two trials tested immediate withdrawal. Bleeding results varied across studies, and several trials were open-label.

Funding

No specific funding; several authors reported industry ties.

Clinical Application

For high-risk stent patients on ticagrelor or prasugrel, consider stopping aspirin at 1–3 months; avoid immediate cessation and clopidogrel extrapolation.