De-escalation of antithrombotic treatment after acute coronary syndrome, a new paradigm.
Andrea RubboliDan AtarDirk SibbingPublished in: Internal and emergency medicine (2024)
After an acute coronary syndrome (ACS) it is imperative to balance the bleeding vs. the ischemic risk given the similar prognostic impact of the two events. Since the post-discharge bleeding risk is substantially stable over time whereas the ischemic risk accumulates in the first weeks to months, a strategy of de-escalation of antithrombotic treatment, consisting in the reduction of either the duration (i.e., early interruption of one antiplatelet agent) or the intensity (i.e., switching from the more potent P2Y 12 -inhibitors prasugrel or ticagrelor to clopidogrel) of dual antiplatelet therapy (DAPT), has been proposed. Reducing the intensity of DAPT can be carried out as a default strategy (unguided approach) or based on the results of either platelet function tests or genetic tests (guided approach). Overall, all de-escalation strategies have shown to consistently decrease bleeding events with no apparent increase in ischemic events as compared to 12-month standard-of-care DAPT. Owing however to several limitations and weaknesses of the available evidence, de-escalation strategies are currently not recommended as a routine, but should rather be considered for selected ACS patients, such as those at increased risk of bleeding.
Keyphrases
- acute coronary syndrome
- antiplatelet therapy
- percutaneous coronary intervention
- atrial fibrillation
- st segment elevation myocardial infarction
- st elevation myocardial infarction
- open label
- end stage renal disease
- healthcare
- chronic kidney disease
- high intensity
- coronary artery disease
- magnetic resonance imaging
- ejection fraction
- clinical trial
- peritoneal dialysis
- cerebral ischemia
- randomized controlled trial
- pain management
- gene expression
- health insurance
- copy number
- diffusion weighted imaging
- combination therapy