Diana Gorog; Jurriën Ten Berg; Gianluca Campo; Tobias Geisler; Bruna Gigante; Erik Grove; Sigrun Halvorsen; Kurt Huber; Young-Hoon Jeong; Gregory Lip; Eliano Navarese; Andrea Rubboli; Jolanta Siller Matula; Robert Storey; Marco Valgimigli; Christophe Vandenbriele; Gemma Vilahur; Ingo Ahrens; Jose Ferreiro

doi:10.4244/EIJ-E-26-00003

Antithrombotic therapy for secondary prevention in patients with acute coronary syndromes treated with percutaneous coronary intervention: options for personalization to reduce bleeding or ischaemic risks

Diana A. Gorog¹^,², MD, PhD; Jurriën M. ten Berg³^,⁴, MD, PhD; Gianluca Campo⁵, MD, PhD; Tobias Geisler⁶, MD, MHBA; Bruna Gigante⁷^,⁸, MD, PhD; Erik L. Grove⁹^,¹⁰, MD, PhD; Sigrun Halvorsen¹¹^,¹², MD, PhD; Kurt Huber¹³, MD; Young-Hoon Jeong¹⁴^,¹⁵, MD, PhD; Gregory Y. H. Lip¹⁶^,¹⁷^,¹⁸, , MD; Eliano P. Navarese¹⁹, MD, PhD; Andrea Rubboli²⁰^,²¹, MD; Jolanta M. Siller Matula²², MD, PhD; Robert F. Storey²³^,²⁴, MD, DM; Marco Valgimigli²⁵^,²⁶, MD, PhD; Christophe Vandenbriele²⁷^,²⁸, MD, PhD; Gemma Vilahur²⁹^,³⁰, DVM, PhD; Ingo Ahrens³¹^,³², MD; Jose Luis Ferreiro³³^,³⁴, MD, PhD

1. Faculty of Medicine, National Heart and Lung Institute, Imperial College, Dovehouse Street, London SW3 6LY, United Kingdom; 2. Centre for Health Services Research, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, Hertfordshire AL10 9AB, United Kingdom; 3. St Antonius Hospital, St Antonius Hospital, Nieuwegein, The Netherlands; 4. Cardiology Department, Maastricht University Medical Center, Maastricht, The Netherlands; 5. Cardiology Division, Azienda Ospedaliero Universitaria di Ferrara, Ferrara, Italy; 6. Department of Cardiology and Angiology, University Hospital, Tübingen, Germany; 7. Division of Cardiovascular Medicine, Department of Medicine, Karolinska Institutet, Stockholm, Sweden; 8. Department of Cardiology, Danderyds Hospital, Stockholm, Sweden; 9. Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; 10. Department of Clinical Medicine, Faculty of Health, Palle Juul-Jensens Boulevard 11, 8200 Aarhus University, Aarhus, Denmark; 11. Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway; 12. Department of Cardiology, University of Oslo, Oslo, Norway; 13. Austrian Heart Foundation, Vienna, Austria and Medical Private University Burgenland (MPUB), Pinkafeld/Oberwart, Austria; 14. CAU Thrombosis and Biomarker Center, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, South Korea; 15. Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, South Korea; 16. Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, Liverpool, United Kingdom; 17. Cardiology Department, Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; 18. Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; 19. Clinical Experimental Cardiology, Clinical and Interventional Cardiology, University of Sassari, Sassari, Sardinia, Italy; 20. Department of Emergency, Internal Medicine, and Cardiology, Division of Cardiology, S. Maria Delle Croci Hospital, Ravenna, Italy; 21. School of Medicine, University of Bologna, Bologna, Italy; 22. Department of Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria; 23. Cardiovascular Research Unit, Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK; 24. NIHR Sheffield Biomedical Research Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom; 25. Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland; 26. Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland; 27. Department of Critical Care, Royal Brompton & Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom; 28. Cardiology and Cardiac Intensive Care, Heart Center, OLV Hospital Aalst, Aalst, Belgium; 29. Research Institute, Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain; 30. CiberCV, Institute Carlos III, Madrid, Spain; 31. Department of Cardiology and Medical Intensive Care, Augustinerinnen Hospital, Academic Teaching Hospital University of Cologne, Cologne, Germany; 32. Heart Centre, Medical Faculty University of Freiburg, Freiburg, Germany; 33. Department of Cardiology, Joan XXIII University Hospital—IISPV, CIBER-CV, 4 Doctor Mallafré Guasch Street, Tarragona ZIP 43005, Spain; 34. Cardiology Department, Rovira i Virgili University, Tarragona, Spain

Abstract

Dual antiplatelet therapy (DAPT) is required to prevent atherothrombotic events in patients with acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI). The default DAPT strategy, namely a potent P2Y₁₂ inhibitor combined with aspirin for 12 months, exposes many patients to excess bleeding risk. Over the past years, alternative antithrombotic regimens have been proposed to reduce bleeding (DAPT abbreviation or de-escalation) or ischaemic (prolonged dual antithrombotic therapy) events. Abbreviation or de-escalation of DAPT is supported by (i) multiple trials showing these strategies to significantly reduce bleeding, particularly for the 20–40% of patients classified as high bleeding risk (HBR); (ii) low prevalence of stent thrombosis and recurrent myocardial infarction beyond 1–3 months post-ACS with the latest generation of drug-eluting stents, and (iii) the recognition that HBR is far more prevalent than high ischaemic risk. Amongst patients at HBR, standard DAPT, in comparison to abbreviated or de-escalated DAPT, increases the net risk of major adverse events, even in the presence of high ischaemic risk. Conversely, amongst patients at high ischaemic risk, without HBR, prolonged dual antithrombotic therapy reduces longer-term thrombotic risk. Recognizing risk factors and assessing the magnitude of bleeding and ischaemic risks are essential. Since there are no ideal scoring systems to balance ischaemic and bleeding risks, and many overlap, focus should be on managing the risk most amenable to modification, namely bleeding, which should dominate the decision-making over ischaemic risk when choosing a DAPT regimen. This document provides practical advice regarding best practice for personalizing DAPT in patients with ACS undergoing PCI, with evidence-based clinical consensus statements on selecting the most appropriate antiplatelet strategy to optimize clinical outcomes.

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Antithrombotic therapy for secondary prevention in patients with acute coronary syndromes treated with percutaneous coronary intervention: options for personalization to reduce bleeding or ischaemic risks

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