Antiplatelet therapy in acute coronary syndrome: a systematic critical appraisal of current guidelines

The purpose of this study was to critically assess acute coronary syndrome (ACS) antiplatelet therapy clinical practice guidelines (CPGs) and to compile the principal recommendations therein.

We systematically searched the literature between January 1, 2015 and June 29, 2025 to retrieve CPGs pertaining to antiplatelet therapy for ACS. Each CPG that met the inclusion criteria was subjected to a methodological quality assessment based on the six domains specified by the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool. The basic characteristics and proposed recommendations of each included CPG were systematically retrieved and subjected to comparative analysis.

From the 8,190 records initially identified, a final set of 22 CPGs was deemed eligible for inclusion. The included CPGs achieved a mean AGREE II score of 70.3%. "Clarity of presentation" emerged as the highest-scoring domain (96.0%), whereas "editorial independence" was the lowest (53.5%). Antiplatelet treatment of ACS is related to the types of ACS, age, gender, treatment duration and bleeding risk. CPGs recommend dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor antagonist (ticagrelor, prasugrel, and clopidogrel).

There is considerable room for enhancing the methodological quality of CPGs focused on antiplatelet therapy for ACS. A dual antiplatelet therapy (DAPT) regimen comprising aspirin and a P2Y12 inhibitor was advised for the majority of patients presenting with ACS. Ticagrelor is the first-line choice, followed by prasugrel or clopidogrel as alternatives. In general, the duration of DAPT should be at least 12 months. Genetic testing and platelet function testing is not routinely recommended for ACS patients.