Aspirin Withdrawal in Patients with Coronary Artery Disease (JACC September 2026-2)-Article: Aspirin Withdrawal in Patients with Coronary Artery Disease

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This JACC state-of-the-art review examines when aspirin can be safely withdrawn in patients with coronary artery disease (CAD) to reduce bleeding while preserving protection against ischemic events.<br /><br />Aspirin has long been the foundation of secondary prevention in CAD, especially after acute coronary syndrome (ACS) and percutaneous coronary intervention (PCI), usually combined with a P2Y12 inhibitor as dual antiplatelet therapy (DAPT). While DAPT lowers risks such as myocardial infarction and stent thrombosis, it increases bleeding. In patients who also need oral anticoagulation (OAC), adding aspirin often raises bleeding risk without clear ischemic benefit.<br /><br />The review explains the pharmacologic rationale for aspirin withdrawal and summarizes trial evidence across several settings:<br />- very early after ACS/PCI,<br />- after 1–3 months of DAPT,<br />- after prolonged DAPT,<br />- and in patients requiring OAC.<br /><br />Overall, the strongest evidence supports aspirin withdrawal after 1–3 months of DAPT when followed by P2Y12 inhibitor monotherapy, especially with ticagrelor. This strategy consistently reduces bleeding without increasing ischemic events in many patients, particularly after the early high-risk period. Clopidogrel monotherapy also appears beneficial in some long-term maintenance settings, but results are more variable and seem largely driven by East Asian populations. Early aspirin withdrawal immediately after PCI or within the first month after ACS may be risky in high-thrombotic-risk patients. In patients with concomitant OAC, aspirin discontinuation is generally favored, and long-term OAC monotherapy is often preferred.<br /><br />Current guidelines still support standard DAPT durations, but increasingly allow aspirin-free strategies in selected patients, especially those at high bleeding risk. The review concludes that aspirin withdrawal is a major shift in CAD management, but patient selection, timing, choice of P2Y12 inhibitor, and the role of genetic or platelet-function testing remain important unanswered questions.

Meta Tag

Concept Aspirin

Concept P2Y12 Inhibitor

Concept Dual Antiplatelet Therapy

Concept Oral Anticoagulation

Concept Thrombosis Risk

Keywords

aspirin withdrawal

coronary artery disease

dual antiplatelet therapy

P2Y12 inhibitor monotherapy

ticagrelor

clopidogrel

acute coronary syndrome

percutaneous coronary intervention

oral anticoagulation

bleeding risk

Aspirin

P2Y12 Inhibitor

Dual Antiplatelet Therapy

Oral Anticoagulation

Thrombosis Risk