Antithrombotic Therapy in Primary and Secondary Prevention of Coronary Artery Disease

Antithrombotic therapy is central to the management of coronary artery disease (CAD), yet its optimal use requires a continuous balance between ischemic protection and bleeding risk. While aspirin has historically been the cornerstone of treatment, contemporary evidence supports a transition toward increasingly individualized strategies across the spectrum of disease. In primary prevention, the role of aspirin remains marginal and is limited to carefully selected high-risk individuals. Following percutaneous coronary intervention (PCI), dual antiplatelet therapy (DAPT) remains the standard of care; however, both its duration and composition are progressively tailored according to patient-specific ischemic and bleeding risk profiles. In chronic coronary syndromes, shorter DAPT followed by single antiplatelet therapy—particularly P2Y12 inhibitor monotherapy—has emerged as an effective bleeding-avoidance strategy without compromising ischemic outcomes. In acute coronary syndromes, 12 months of DAPT remains the recommended approach, although de-escalation strategies may be considered in selected patients at lower ischemic risk. For long-term secondary prevention, emerging evidence suggests a potential advantage of clopidogrel over aspirin, while in patients with persistently high ischemic risk, intensified antithrombotic regimens may provide additional benefit. Special populations require tailored treatment strategies. Overall, contemporary evidence supports a paradigm shift toward a precision medicine approach in CAD, in which antithrombotic therapy is dynamically adapted to the individual balance between ischemic and bleeding risk to optimize long-term clinical outcomes.