Optimal antiplatelet and anticoagulation strategies in acute coronary syndromes

Area of Science:

• Cardiology
• Pharmacology
• Clinical Medicine

Background:

• Antithrombotic therapy in acute coronary syndrome (ACS) presents challenges due to patient-specific thrombotic and bleeding risks.
• Factors like advanced age, comorbidities (renal failure, atrial fibrillation), and interventions (transcatheter valve procedures) necessitate individualized antithrombotic strategies.
• Novel stent designs promote faster endothelialization, making shortened or de-escalated antiplatelet therapies a viable option to reduce bleeding.

Purpose of the Study:

• To review current evidence on antithrombotic strategies for ACS patients.
• To provide practical recommendations for tailoring therapy based on individual bleeding and thrombo-ischemic risk.
• To address the management of patients with both ACS and atrial fibrillation (AF).

Main Methods:

• Review of recent clinical trials and guidelines.
• Analysis of factors influencing bleeding and ischemic risk in ACS patients.
• Synthesis of evidence for de-escalation, monotherapy, and intensified antithrombotic approaches.

Main Results:

• Shortening or de-escalating antiplatelet therapy can reduce bleeding events in ACS.
• Patients with ACS and AF benefit from individualized combination therapy (antiplatelet plus non-vitamin K oral anticoagulants) to lower bleeding risk.
• Prolonged intensified antithrombotic therapy is recommended for ACS patients with high long-term ischemic risk.

Conclusions:

• Individualized antithrombotic therapy is essential for ACS patients, balancing bleeding and ischemic risks.
• De-escalation strategies are beneficial for high-bleeding-risk patients, while intensified therapy is indicated for high-ischemic-risk patients.
• Specific recommendations are provided for tailoring antithrombotic treatment post-ACS based on risk stratification.