Optimal antiplatelet and anticoagulation strategies in acute coronary syndromes
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Herz https://doi.org/10.1007/s00059-020-04947-7
Department of Cardiology and Angiology, University Hospital Tübingen, Tübingen, Germany
© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2020
Optimal antiplatelet and anticoagulation strategies in acute coronary syndromes
In the past, one-size-fits-all antithrombotic strategies were mostly applied for patients with acute coronary syndrome (ACS). However, because of increasing comorbidities and age, a more individualized focus taking into account a dynamic risk assessment is warranted. A hypothetical construct underlines that during the different phases after ACS, the focus of antithrombotic therapy changes. Whereas in the early and periprocedural phase the focus lies on effective platelet and thrombin inhibition, in the intermediate phase, ranging from hospital discharge to the first 3 months, weighing the benefit of more vs. less intensified antiplatelet therapy against the risk of ischemia vs. bleeding becomes more important. In some patients with tolerable bleeding risk, the atherothrombotic risk due to clinical risk factors and persistent platelet and thrombin activation might clearly outweigh bleeding
risk. These patients benefit from prolonged antithrombotic strategies in the transition from post-acute to chronic coronary syndrome (. Fig. 1). Subsequently, we aim to give an overview of the recent evidence regarding individualized antithrombotic strategies in ACS.
Identification of bleeding and ischemic risk Knowledge of the individual bleeding and ischemic risk is essential to determine the optimal duration and intensity of antithrombotic therapy. Since some risk factors may vary over time, it is necessary to implement strategies to reconsider risk. The Academic Research Consortium (ARC) recently published a consensus paper defining major and minor criteria for definition of high bleeding risk (HBR) (. Table 1; [1]). In
addition, several scores have been developed to discriminate between bleeding and ischemic risk. The PRECISE-DAPT score includes variables that are associated with both ischemic and bleeding risk and has been implemented into current guidelines to differentiate the net clinical benefit of a prolonged DAPT (www.precisedaptscore.com/predapt/ webcalculator.html; [2]). A cut-off value of ≥25 defines a prevailing HBR [3, 4]. Biomarkers and genetic variants have been associated with thrombotic risk (e.g., D-dimer, high-sensitivity [hs]-troponin, fibrinopeptide A, CYP2C19 loss of function, miRNAs) and bleeding risk (e.g., GDF-15, CYP2C19 gain of function, miRNAs), but data showing the added benefit and practicability to guide intensity and duration of antithrombotic therapy after ACS are still sparse or inconclusive.
ACS +/-PCI Stable/Intermediate Phase- Minimum Duraon of DAPT
Acute Phase Focus effecve inhibion of platelet aggregaon
Chronic phase, stent independent risk
Weighing PCI related risk versus bleeding risk
Balancing stent-independent ischemic versus bleeding risk:
12 months DAPT 6 months in bleeding risk paents
Vessel Disease in
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