Moving from dual antiplatelet therapy to monotherapy based on P2Y₁₂ receptor blockade-why it could be a novel paradigm?

Pivotal clinical trials conducted in the bare metal stent and first-generation drug-eluting stent (DES) eras established the superiority of dual antiplatelet therapy (DAPT) over aspirin monotherapy in preventing ischemic events. Nonetheless, recent advances in stent technology improved the safety profile of these devices, lowered the risk of stent thrombosis, and reduced the need for prolonged DAPT. Furthermore, several studies have shown that the bleeding associated with prolonged DAPT confers an increase in mortality following percutaneous coronary intervention (PCI). Hence, DAPT strategies that minimize the bleeding risk and conserve the ischemic protection became an utmost need. While several studies have shown that short DAPT durations followed by aspirin monotherapy may be safe and feasible in relatively low-risk patients, extrapolation to higher risk patients remains uncertain. Even though aspirin has been the most widely used antiplatelet drug for many decades, recent evidence suggests potential benefits with the use of P2Y₁₂ inhibitor monotherapy after a shortened DAPT duration in patients undergoing percutaneous coronary intervention with current-generation DESs. This concept is even being taken one step further as P2Y₁₂ inhibitor monotherapy after PCI is currently being investigated in selected patients.