P2Y(12) inhibitor monotherapy in patients undergoing percutaneous coronary intervention

Abstract

The evolution of stent design has reduced the incidence of stent thrombosis, meaning that the duration of dual antiplatelet therapy after percutaneous coronary intervention (PCI) might be shortened. In this Review, the authors describe the current evidence base and ongoing clinical trials into the use of P2Y(12) inhibitor monotherapy after PCI. For 20 years, dual antiplatelet therapy (DAPT), consisting of the combination of aspirin and a platelet P2Y(12) receptor inhibitor, has been the gold standard of antithrombotic pharmacology after percutaneous coronary intervention (PCI). In the past 5 years, several investigations have challenged this paradigm by testing the efficacy and safety of P2Y(12) inhibitor monotherapy (that is, without aspirin) following a short course of DAPT. Collectively, these studies suggested a reduction in the risk of major bleeding and no significant increase in thrombotic or ischaemic events compared with guideline-recommended DAPT. Current recommendations are evolving to inform clinical practice on the ideal candidates for P2Y(12) inhibitor monotherapy after PCI. Generalizing the results of studies of P2Y(12) inhibitor monotherapy requires a thorough understanding of their design, populations, interventions, comparators and results. In this Review, we provide an up-to-date overview on the use of P2Y(12) inhibitor monotherapy after PCI, including supporting pharmacodynamic and clinical evidence, practical recommendations and future directions.