De-escalation strategies in patients with acute coronary syndrome: a step towards precision medicine

ABSTRACT

Introduction

Dual antiplatelet therapy (DAPT) with aspirin and a P2Y₁₂ inhibitor is a cornerstone in the treatment of patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). Current international guidelines recommend the use of 12 months of DAPT with newer P2Y₁₂ inhibitors (i.e. ticagrelor or prasugrel) as first-line therapy in this setting. However, intense and prolonged DAPT regimens are associated with an increased risk of bleeding, with relevant prognostic implications. Recently, a strategy of de-escalation of P2Y₁₂ inhibitors has been proposed as an alternative to conventional DAPT to mitigate the risk of bleeding while preserving ischemic protection after ACS.

Areas covered

In this review, we summarize the available evidence on guided and unguided strategies for P2Y₁₂ inhibitor de-escalation in patients with ACS undergoing PCI.

Expert Opinion

Among patients with ACS, guided and unguided de-escalation strategies are safe and effective for secondary cardiovascular prevention. Although the implementation of genetic and platelet function tests is of interest for treatment personalization, the routine use of guided de-escalation strategies seems impractical. In this context, unguided de-escalation approaches appear more attractive, convenient, and suitable for contemporary practice.

KEYWORDS:

• DAPT
• De-escalation
• P2Y₁₂ inhibitor
• Guided therapy
• Platelet function tests

Article highlights

• Dual antiplatelet therapy (DAPT) represents the standard of care in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI).

• In selected cases, current guidelines recommend the use of P2Y₁₂ inhibitor de-escalation as a possible alternative to standard DAPT to reduce bleeding risk based on the evidence from randomized trials and meta-analyses demonstrating the safety and efficacy of this strategy.

• The choice between guided and unguided de-escalation is generally left to the discretion of the physician, based on the clinical setting and center experience.

• Although a guided approach is of interest for a more tailored treatment, its routine use seems impractical in contemporary healthcare systems; conversely, unguided P2Y₁₂ inhibitor de-escalation is potentially attractive and more suitable for contemporary practice.

• In this review, we discuss the available evidence on this topic and provide an overview of randomized trials and meta-analyses examining the safety and efficacy of de-escalation strategies in patients with ACS undergoing PCI.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.