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Updated: Jun 28, 2025
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
De-escalation of antithrombotic treatment after acute coronary syndrome, a new paradigm
Andrea Rubboli1, Dan Atar2,3, Dirk Sibbing4,5
1Department of Emergency, Internal Medicine and Cardiology, Division of Cardiology, S. Maria delle Croci Hospital, Viale Randi 5, 48121, Ravenna, Italy. andrearubboli@libero.it.
Insights
De-escalating dual antiplatelet therapy (DAPT) after acute coronary syndrome (ACS) reduces bleeding without increasing ischemic events. This strategy is best for select ACS patients at high bleeding risk.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Medicine
Background:
- Balancing bleeding and ischemic risk is crucial after acute coronary syndrome (ACS).
- Ischemic risk is highest early post-discharge, while bleeding risk remains stable.
- Dual antiplatelet therapy (DAPT) is standard but carries bleeding risks.
Purpose of the Study:
- To evaluate de-escalation strategies for antithrombotic treatment post-ACS.
- To assess the impact of reducing DAPT duration or intensity on clinical outcomes.
- To determine if de-escalation is safe and effective compared to standard DAPT.
Main Methods:
- De-escalation strategies involve reducing DAPT duration or switching P2Y12 inhibitors (e.g., ticagrelor/prasugrel to clopidogrel).
- Approaches include unguided (default) or guided (using platelet/genetic tests) de-escalation.
- Outcomes compared were bleeding events and ischemic events versus 12-month standard DAPT.
Main Results:
- All DAPT de-escalation strategies consistently reduced bleeding events.
- No significant increase in ischemic events was observed compared to standard DAPT.
- De-escalation strategies demonstrated a favorable bleeding profile.
Conclusions:
- DAPT de-escalation strategies show promise in reducing bleeding post-ACS.
- Current evidence suggests these strategies are not for routine use but for selected high-bleeding-risk patients.
- Further research is needed to address limitations in existing evidence for widespread adoption.
Abstract:
After an acute coronary syndrome (ACS) it is imperative to balance the bleeding vs. the ischemic risk given the similar prognostic impact of the two events. Since the post-discharge bleeding risk is substantially stable over time whereas the ischemic risk accumulates in the first weeks to months, a strategy of de-escalation of antithrombotic treatment, consisting in the reduction of either the duration (i.e., early interruption of one antiplatelet agent) or the intensity (i.e., switching from the more potent P2Y12-inhibitors prasugrel or ticagrelor to clopidogrel) of dual antiplatelet therapy (DAPT), has been proposed. Reducing the intensity of DAPT can be carried out as a default strategy (unguided approach) or based on the results of either platelet function tests or genetic tests (guided approach). Overall, all de-escalation strategies have shown to consistently decrease bleeding events with no apparent increase in ischemic events as compared to 12-month standard-of-care DAPT. Owing however to several limitations and weaknesses of the available evidence, de-escalation strategies are currently not recommended as a routine, but should rather be considered for selected ACS patients, such as those at increased risk of bleeding.
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