Insights on DAPT Abbreviation and De-escalation from ULTIMATE-DAPT and Related Trials: Are we Heading Toward an Aspirin-Free Strategy?

The results of the recently concluded ULTIMATE-DAPT and T-PASS trials strongly support the emerging concept of antiplatelet monotherapy in patients at high bleeding risk undergoing percutaneous coronary intervention. Monotherapy with more potent antiplatelets such as ticagrelor is both a safe and an equally effective strategy to circumvent major bleeding episodes in patients at high bleeding risk while guarding against ischemic events. Although these results were not replicated with low-dose prasugrel monotherapy in the STOP-DAPT-3 trial, the other major trials investigating ticagrelor monotherapy (GLOBAL-LEADERS and TWILIGHT-ACS) suggested the feasibility and appropriateness of abbreviating the dual antiplatelet therapy (DAPT) as early as 1-3 months of the index procedure. Moreover, the recent data from TICO, T-PASS, and now the ULTIMATE-DAPT trial, hint toward early switchover to ticagrelor monotherapy without any undue concern of increased ischemic events. However, on closer examination, we find that study cohorts in most trials had lower anatomical complexity of coronary lesions and most adopted imaging-based revascularization strategies. Among these trials, those that achieved convincing levels of safety in ischemic endpoints mainly administered ticagrelor monotherapy. Can monotherapy with these newer antiplatelets sufficiently obviate the need for year-long DAPT? Can such antiplatelet monotherapy remain effective in all coronary artery disease subsets? Can we start patients solely on a single antiplatelet from day one of the procedure? These are some of the questions we attempt to answer by revisiting the results from these trials.