Antiplatelet Therapy in East Asian Patients With Acute Coronary Syndrome: Current Evidence and Evolving Strategies

Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is the standard of care after acute coronary syndrome (ACS) treated with percutaneous coronary intervention.Although Western randomized trials established 12 months of potent DAPT as the reference regimen, East Asian patients were substantially underrepresented in these studies.East Asians generally have a lower ischemic risk but a higher bleeding risk than Western populations.This phenomenon, known as the "East Asian Paradox," raises concerns about directly applying Western DAPT strategies to this population.Evidence from East Asian studies suggests that prolonged potent DAPT does not consistently reduce ischemic events but does increase bleeding risk.Randomized trials in East Asian patients with ACS have demonstrated higher bleeding rates with ticagrelor, whereas studies evaluating shortterm DAPT followed by potent P2Y12 inhibitor monotherapy have generally suggested reduced bleeding without an excess of ischemic events.Reduced-dose prasugrel appears to provide effective platelet inhibition while lowering bleeding risk.De-escalation strategies, such as reducing the potency of the P2Y12 inhibitor within DAPT after the acute phase-