De-escalation in intensity or duration of dual antiplatelet therapy in patients with coronary artery disease: More than alternative treatment options.

Antithrombotic therapy represents the mainstay of pharmacological treatments in patients with acute or chronic coronary syndrome (CCS) undergoing percutaneous coronary intervention (PCI) [ [1] De Servi S. Landi A. Savonitto S. et al. Tailoring oral antiplatelet therapy in acute coronary syndromes: from guidelines to clinical practice. J Cardiovasc Med. 2023; 24 Crossref Scopus (1) Google Scholar ]. Since the CURE study [ [2] Mehta S.R. Yusuf S. Peters R.J.G. et al. Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study. Lancet. 2001; 358: 527-533 Abstract Full Text Full Text PDF PubMed Scopus (3042) Google Scholar ], dual antiplatelet therapy (DAPT) consisting of aspirin and an oral P2Y12 inhibitor has represented the standard of care for acute coronary syndrome (ACS) or PCI patients due to the greater ischemic protection compared with aspirin alone. Current guidelines recommend 6 or 12 months as default DAPT durations in patients with CCS or ACS undergoing PCI, respectively [ [3] Valgimigli M. Bueno H. Byrne R.A. et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS. Eur Heart J. 2018; 39: 213-260 Crossref PubMed Scopus (1840) Google Scholar , [4] Collet J.-.P. Thiele H. Barbato E. et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021; 42: 1289-1367 Crossref PubMed Scopus (1705) Google Scholar ]. Yet, there is mounting evidence suggesting that prolonging DAPT is unavoidably associated with higher risks of major bleeding which carry similar or even worse impact on mortality than a recurrent myocardial infarction (MI) [ [5] Valgimigli M. Landi A. Ischemic and bleeding risk in patients with acute coronary syndrome undergoing complex percutaneous coronary intervention: is it time to REACT?. Eur Heart J Acute Cardiovasc Care. 2021; 10: 1125-1128 Crossref PubMed Google Scholar ].