Weekly Journal Scan: PREMIUM evidence that aspirin omission in STEMI patients undergoing primary percutaneous coronary intervention is unjustified and unsafe

Comment on ‘Aspirin Omission at the Time of Primary Percutaneous Coronary Intervention in STEMI’ which was published in The New England Journal of Medicine, https://doi.org/10.1056/NEJMoa2606997. DAPT with low-dose aspirin and a P2Y12 inhibitor remains the default treatment strategy for 12 months after an acute coronary syndrome (ACS) in patients without high bleeding risk.2 Its rationale extends beyond the prevention of stent thrombosis, as the simultaneous inhibition of thromboxane A2- and adenosine diphosphate (ADP)-dependent platelet activation reduces also recurrent atherothrombotic events arising from non-target lesions in the coronary circulation and other vascular territories.3 However, evidence from randomized trials and meta-analyses has challenged the need for a uniform DAPT strategy, suggesting that shorter DAPT regimens, particularly in appropriately selected patients at low ischaemic risk, may reduce bleeding without compromising protection against ischaemic events.4–7 The STOPDAPT-3 trial found that immediate aspirin omission with prasugrel monotherapy at the time of PCI in 6002 Japanese patients with ACS or HBR did not reduce major bleedings and was associated with an excess of early coronary events, including stent thrombosis.4 Of note, in the control group, DAPT was maintained for the first month after PCI, followed by aspirin monotherapy, thus testing aspirin withdrawal specifically during the period of highest thrombotic risk rather than a long-term aspirin-free strategy. The NEO-MINDSET trial, in which aspirin was stopped as early as 2 days after PCI for ACS, failed to demonstrate non-inferiority and showed numerically more death, MI, stroke, and a three-fold higher incidence of stent thrombosis.5