De-escalating antiplatelet therapy in patients with acute coronary syndrome

Dual antiplatelet therapy (DAPT), combining aspirin and a P2Y12 receptor inhibitor, is the basis of acute coronary syndrome (ACS) treatment, demonstrating efficacy in reducing ischemic complications while being linked to increased bleeding. Recent interest has emerged in bleeding reduction strategies, specifically de-escalation strategies involving P2Y12 inhibitor potency and dosage modulation that can be achieved in two different ways: the unguided de-escalation, where P2Y12 inhibitors are adjusted based on clinical judgment, and the guided de-escalation, incorporating genetic or platelet function tests to tailor the therapy. Several randomized controlled trials (RCTs) demonstrated that both unguided and guided de-escalation strategies can reduce bleeding without compromising ischemic outcomes. However, some gaps in evidence are still present and further investigation is needed. Ongoing and upcoming RCTs aim to address uncertainties, including direct comparisons between de-escalation strategies, optimal timing for intervention, and personalized approaches guided by genetic testing. Furthermore, the review emphasizes the need for standardization in implementing de-escalation strategies in routine clinical practice.