Weekly Journal Scan: Aspirin and oral anticoagulation—more of a bloody mary than an AQUATIC mix

This comment refers to ‘Aspirin in Patients with Chronic Coronary Syndrome Receiving Oral Anticoagulation’, which was published in The New England Journal of Medicine, doi: 10.1056/NEJMoa2507532. Balancing thrombotic and bleeding risks remains one of the most enduring challenges in the long-term management of patients with coronary artery disease who also require chronic OAC. This dilemma is particularly pronounced among elderly individuals or those with multiple comorbidities, such as AF, diabetes, or chronic kidney disease, who often present overlapping indications for both antiplatelet and anticoagulant therapy.3 Although combining these agents offers theoretical protection against both atherothrombotic and cardioembolic events, it substantially increases the risk of bleeding. Consequently, the optimal long-term antithrombotic strategy beyond the early post-PCI period remains uncertain. Previous randomized controlled trials (RCTs)—such as AUGUSTUS,4 AFIRE,5 OAC-ALONE,6 and EPIC-CAD7—have progressively supported simplification towards OAC monotherapy after an initial combination period. Yet, data have been limited for patients with CCS at increased residual atherothrombotic risk well beyond 6 months post-stenting. Furthermore, most of these studies predominantly involved Asian populations,5–7 who differ from Western cohorts in average body weight, prevalence of small-vessel coronary disease, and bleeding risk profiles. These differences may alter the balance between ischaemic protection and haemorrhagic complications. In addition, many trials were open-label and largely limited to AF patients, further constraining external validity.