A sledgehammer or a scalpel? Refining antithrombotic therapy in anticoagulated ACS patients

Direct oral anticoagulants (DOACs) have become the standard of care for the prevention of thromboembolism in patients with non-valvular atrial fibrillation (AF), but when such patients experience an acute coronary syndrome (ACS), combination treatment with anticoagulant and antiplatelet therapy is required.12 While the combination of aspirin with a potent P2Y12 inhibitor, i.e., prasugrel or ticagrelor, has become the standard of care for most ACS patients, the evidence in favour of potent P2Y12 inhibitors in patients with a parallel indication for anticoagulation is limited.1 Four large randomised studies have explored potential combinations of DOACs with antiplatelet drugs in this setting, focusing on whether a dual or triple antithrombotic strategy should be used in AF patients undergoing percutaneous coronary intervention (PCI) and/or hospitalised for ACS.3456 Collectively, these studies showed the non-inferiority of the combination of a DOAC and a single antiplatelet agent, namely a P2Y12 inhibitor, for ischaemic endpoints and superiority for bleeding, leading to wide adoption of this strategy and its recommendation in guidelines.12 However, despite evidence that omission of aspirin improves...