Optimizing Monotherapy Selection, Aspirin Versus P2Y12 Inhibitors, Following Percutaneous Coronary Intervention

•Although ischemic events are low, bleeding events remain high after PCI.•Aspirin monotherapy after short DAPT appears safe in low-ischemic-risk population.•P2Y12 inhibitor monotherapy post-short DAPT preferred in high-ischemic-risk patients.•Antiplatelet therapy should be based on clinical presentation and risk scores. Dual antiplatelet therapy (DAPT) reduces ischemic and thrombotic events after percutaneous coronary intervention (PCI). Initial reports of higher myocardial infarction and mortality rates prompted guideline committees to choose 12-month duration of DAPT after PCI. However, higher bleeding rates with DAPT remain a major concern. Since these guidelines were published, there have been improvements in stent design, deployment techniques, and antiplatelet therapies, which have reduced ischemic events. To address bleeding concerns, trials were performed to evaluate the effectiveness of short-duration DAPT. Two main strategies were employed: (1) aspirin monotherapy after a short-duration DAPT, and (2) P2Y12 inhibitor monotherapy after a short-duration DAPT. In this review, we outline all the major trials on short-duration DAPT that have examined the previously mentioned strategies and propose a new individualized treatment algorithm for which monotherapy to choose or remove after PCI. In conclusion, while removing the P2Y12 inhibitor after a short DAPT appears to be safe in the low-risk population, removing aspirin and continuing the P2Y12 inhibitor as monotherapy would be the preferred strategy in intermediate- to high-risk patients to mitigate the bleeding risk. Factors that play a role to determine what antiplatelet therapy to choose or drop following PCI. Antiplatelet therapy should be based on clinical presentation and ischemic and bleeding risk scores. [Display omitted]