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De-escalation of antithrombotic treatment after acute coronary syndrome, a new paradigm

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Abstract

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 P2Y12-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.

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Authors and Affiliations

  1. Department of Emergency, Internal Medicine and Cardiology, Division of Cardiology, S. Maria delle Croci Hospital, Viale Randi 5, 48121, Ravenna, Italy

    Andrea Rubboli

  2. Department of Cardiology, Oslo University Hospital Ullevaal, Oslo, Norway

    Dan Atar

  3. Institute of Clinical Medicine, University of Oslo, Oslo, Norway

    Dan Atar

  4. Privatklinik Lauterbacher Mühle am Ostersee, Iffeldorf, Germany

    Dirk Sibbing

  5. Department of Cardiology, Klinikum der Universität München, Ludwig-Maximilians-University, Munich, Germany

    Dirk Sibbing

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  1. Andrea Rubboli
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Correspondence to Andrea Rubboli.

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Rubboli, A., Atar, D. & Sibbing, D. De-escalation of antithrombotic treatment after acute coronary syndrome, a new paradigm. Intern Emerg Med (2024). https://doi.org/10.1007/s11739-024-03590-y

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