Early aspirin discontinuation safe after complete revascularization in acute MI

Among low-risk patients with acute MI who underwent early complete revascularization and received one month of dual antiplatelet therapy (DAPT), P2Y12 inhibitor monotherapy was noninferior to continued DAPT for adverse cardiovascular and cerebrovascular events, while reducing bleeding risk. These late-breaking findings were presented in a Hot Line session today at ESC Congress 2025 and simultaneously published in New England Journal of Medicine.

Current ESC Guidelines recommend 12 months of DAPT − aspirin plus a potent P2Y12 inhibitor − after percutaneous coronary intervention (PCI) for MI. 

No randomized trials have previously assessed early aspirin discontinuation in acute MI patients who achieve early, complete revascularization with modern stents. In such cases, bleeding risk may outweigh residual ischaemic risk, making antiplatelet therapy de-escalation attractive."

Professor Giuseppe Tarantini, Principal Investigator of the TARGET-FIRST trial, University of Padua, Italy

In this open-label randomized controlled trial conducted at 40 European centres, eligible adults with an ST-segment elevation MI (STEMI) or non-STEMI underwent complete revascularization within seven days using a contemporary drug-eluting stent and completed one month of DAPT without adverse events. They were randomized 1:1 to continue DAPT or switch to P2Y12 inhibitor monotherapy for 11 months. The primary endpoint was a composite of all-cause death, MI, stent thrombosis, stroke or Bleeding Academic Research Consortium (BARC) type 3/5 bleeding at 11 months. Noninferiority was defined as an absolute difference ≤1.25 percentage points in the upper bound of the two-sided 95% CI.

The mean age of the 1,942 randomized patients was 61 years and 21.6% were women.

The primary endpoint occurred in 2.10% of the P2Y12 inhibitor monotherapy group and 2.18% of the continued DAPT group (difference -0.09 percentage points; 95% CI -1.39 to 1.20; p=0.021 for noninferiority). MI occurred in 0.7% vs. 1.1%, definite/probable stent thrombosis in 0.1% vs. 0.0% and ischaemic stroke in 0.3% vs. 0.2%, respectively. BARC type 3/5 bleeding occurred in 0.7% in each group.

The main secondary endpoint (BARC type 2/3/5 bleeding) was significantly lower with P2Y12 inhibitor monotherapy (2.65% vs. 5.57%; hazard ratio [HR] 0.46; 95% CI 0.29 to 0.75; p=0.002). The patient-oriented composite outcome (all-cause death, MI, stent thrombosis, stroke, repeat ischaemia-driven revascularization or BARC type 2/3/5 bleeding) occurred in 4.5% in the monotherapy group and 7.2% in the DAPT group (HR 0.61; 95% CI 0.42 to 0.89). Therapy adherence at 11 months was high in both groups (86.9% with monotherapy and 88.6% with DAPT).

Professor Tarantini concluded: "In low-risk acute MI patients with early complete revascularization and no complications after one month of DAPT, switching to P2Y12 inhibitor monotherapy-maintained protection from ischaemic events and reduced bleeding. These results reflect the benefits of modern stents, high procedural success and optimal medical therapy, making early aspirin discontinuation feasible in this selected population."