Individualized Antiplatelet Therapy After Percutaneous Coronary Intervention for Acute Coronary Syndrome

Acute coronary syndrome requires effective antiplatelet therapy after percutaneous coronary intervention (PCI), while contemporary patients often present with overlapping ischemic and bleeding risks. This clinical complexity has shifted post-PCI management from fixed-duration dual antiplatelet therapy (DAPT) toward individualized strategies based on DAPT duration, single antiplatelet therapy (SAPT) selection, and aspirin withdrawal. Aspirin is traditionally the default maintenance agent after DAPT, although long-term aspirin use is limited by gastrointestinal intolerance, mucosal injury, and bleeding risk. P2Y12 inhibitor monotherapy represents an important aspirin-free strategy, with clinical application influenced by drug potency, genetic variability, tolerability, cost, and adherence. Indobufen, a reversible cyclooxygenase-targeting antiplatelet agent, has reemerged as a potential aspirin alternative by suppressing thromboxane A2 generation through a mechanism distinct from that of aspirin. Current evidence suggests that indobufen-based DAPT may provide comparable ischemic protection with fewer bleeding or gastrointestinal adverse events in selected PCI patients, particularly those with aspirin intolerance, gastrointestinal vulnerability, or high bleeding risk. These patients often present with multiple high-risk features that simultaneously elevate both ischemic and bleeding risks, underscoring the need for careful risk stratification. Most available studies have evaluated indobufen as an aspirin substitute within DAPT rather than as SAPT after DAPT discontinuation. From a pharmacoeconomic perspective, indobufen is more expensive than aspirin, although this must be weighed against potential benefits in bleeding reduction. Future randomized trials are needed to define the optimal DAPT-to-SAPT strategy and clarify the clinical position of indobufen in acute coronary syndrome-PCI.