De-escalation versus shortening of dual antiplatelet therapy

Despite a relentless effort to shift the paradigm in antiplatelet strategies towards a reduction of bleeding without any trade-off in thrombotic events—known as bleeding reduction strategies—the latest 2023 European Society of Cardiology (ESC) Guidelines have reaffirmed a standard 12-month dual antiplatelet therapy (DAPT) with a potent agent (prasugrel or ticagrelor) as the primary strategy for patients with acute coronary syndrome (ACS), limiting the use of clopidogrel in the cases where prasugrel and ticagrelor are unavailable, contraindicated, or cannot be tolerated, including older patients with high bleeding risk (HBR).1,2 Bleeding reduction strategies are primarily characterized by shortening DAPT or de-escalating P2Y12 inhibiting therapy.2–4 Short DAPT may be achieved by stopping aspirin or the P2Y12 inhibitor 1–6 months after ACS.2,3 On the other hand, de-escalation of P2Y12 inhibiting therapy may be either guided or unguided, depending on the use or not of platelet function or genetic testing to guide clopidogrel administration based on individual patient responsiveness, and can be achieved by switching from a more potent (i.e. prasugrel or ticagrelor) to a less potent (i.e. clopidogrel) P2Y12 inhibitor or by reducing the dose of a potent P2Y12 inhibitor.2,3