August 25, 2022Frontiers in Cardiovascular Medicine38 citationsOpen Access
De-escalation of antiplatelet therapy in acute coronary syndromes: Why, how and when?
Key Result
De-escalation of antiplatelet therapy represents a promising strategy for reducing bleeding without any trade-off in ischemic events in patients with acute coronary syndrome.
Structured PICO
Does a de-escalation strategy of antiplatelet therapy reduce bleeding without increasing ischemic events in patients with acute coronary syndrome?
P
Population
Patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI)
I
Intervention
De-escalation strategies of antiplatelet therapy (including shortening dual antiplatelet therapy duration or modulating P2Y12 inhibition via guided or unguided approaches)
C
Comparator
Standard 12-month dual antiplatelet therapy (DAPT) with aspirin and a potent P2Y12 inhibitor (prasugrel or ticagrelor)
De-escalation of antiplatelet therapy in ACS, particularly through guided modulation of P2Y12 inhibition, represents a promising approach to personalize treatment by reducing bleeding risk without compromising ischemic protection.
Limitations
- Many studies have been performed on Asian populations, limiting the generalization of their results to other ethnicities.
- Frequent use of non-inferiority designs with primary endpoints including both bleeding and ischemic events.
- Reduced statistical power for hard ischemic and bleeding events in available trials.
Abstract
inhibitor (prasugrel or ticagrelor), the so called dual antiplatelet treatment (DAPT), has represented the antithrombotic regimen of choice in patients with acute coronary syndrome (ACS) for nearly a decade. Nevertheless, the use of such antiplatelet treatment regimen, while reduced the risk of thrombotic complications, it is inevitably associated with increased bleeding and this risk may outweigh the benefit of a reduction of ischemic events in specific subgroup of patients. In light of the adverse prognostic implications of a bleeding complication, there has been a great interest in the development of antiplatelet regimens aimed at reducing bleeding without any trade-off in ischemic events. The fact that the ischemic risk is highest in the early phase after an ACS while the risk of bleeding remains relatively stable over time has represented the rationale for the implementation of a more intense antithrombotic regimen early after an ACS, followed by a less intense antithrombotic regimen thereafter. This practice, known as a "de-escalation" strategy, represents one of the more promising approaches for personalization of antithrombotic therapy in ACS. In this review we discuss the rationale, appraise the evidence and provide practical recommendations on the use of a de-escalation strategy of antiplatelet therapy in patients with an ACS.