De-escalation of antiplatelet therapy in acute coronary syndromes: Why, how and when?

Abstract

The synergistic blockade of the key platelet signaling pathways of cyclooxygenase-1 blockade and P2Y12 signaling by combining aspirin plus a potent P2Y12 inhibitor (prasugrel or ticagrelor), the so called dual antiplatelet treatment (DAPT), has represented the antithrombotic regimen of choice in patients with acute coronary syndrome (ACS) for nearly a decade. Nevertheless, the use of such antiplatelet treatment regimen, while reduced the risk of thrombotic complications, it is inevitably associated with increased bleeding and this risk may outweigh the benefit of a reduction of ischemic events in specific subgroup of patients. In light of the adverse prognostic implications of a bleeding complication, there has been a great interest in the development of antiplatelet regimens aimed at reducing bleeding without any trade-off in ischemic events. The fact that the ischemic risk is highest in the early phase after an ACS while the risk of bleeding remains relatively stable over time has represented the rationale for the implementation of a more intense antithrombotic regimen early after an ACS, followed by a less intense antithrombotic regimen thereafter. This practice, known as a “de-escalation” strategy, represents one of the more promising approaches for personalization of antithrombotic therapy in ACS. In this review we discuss the rationale, appraise the evidence and provide practical recommendations on the use of a de-escalation strategy of antiplatelet therapy in patients with an ACS.

Management of Coronary Artery Disease in Older Adults: Recent Advances and Gaps in Evidence

“…As previously discussed, the management of CAD in older adults requires a multidimensional clinical approach that goes beyond pre-defined therapeutic and nosographic algorithms ( Figure 3 ). For instance, older adults are at high risk of both ischemic and bleeding events [ 38 ]. Multivessel disease is also frequent in old age [ 39 ].…”

Advancements in Percutaneous Coronary Intervention Techniques: A Comprehensive Literature Review of Mixed Studies and Practice Guidelines

“…One such treatment regimen is DAPT, which involves the combination of two antiplatelet agents, typically aspirin and a P2Y12 receptor blocker, to lower the likelihood of thrombotic events in individuals who have a diagnosis of ACS or who have had a PCI [ 49 ]. In recent years, increasing interest has been in de-escalating DAPT to lower the bleeding risk complications while maintaining efficacy [ 50 ].…”

Editorial: Precision medicine for antithrombotic therapy in patients after percutaneous coronary interventions

“…The ever growing understanding of the prognostic impact of bleeding events, the availability of less thrombogenic stent platforms and the notion that the ischemic risk is highest during the first 1-3 months after PCI/ACS, have fueled interest in implementing the socalled "de-escalation" strategies (6,7). A comprehensive appraisal of these strategies is provided in the review article by Marie Muthspiel et al while the network meta-analysis by Oumaima El Alaoui El Abdallaoui et al allows for a direct and indirect comparison between different de-escalation strategies among 42,511 patients from 10 randomized controlled trials (RCTs).…”