Cutting-Edge Cardiology: Individualizing Antiplatelet Therapy for Optimal Acute Coronary Syndrome Outcomes

Dual antiplatelet therapy (DAPT), consisting of aspirin and a P2Y12 inhibitor, is fundamental after percutaneous coronary intervention (PCI) in acute coronary syndromes (ACSs). Recent evidence supports moving from a uniform to an individualized approach, tailoring therapy duration and intensity to patient-specific ischemic and bleeding risks. A targeted literature review was conducted in PubMed, MEDLINE, Scopus, and Google Scholar from inception to June 2025. Relevant MeSH and free-text terms included "acute coronary syndromes, dual antiplatelet therapy, percutaneous coronary intervention, ticagrelor, prasugrel, clopidogrel, de-escalation, abbreviated therapy, rivaroxaban, and dual pathway inhibition." Boolean operators were applied, and studies were restricted to English-language publications in humans. Case reports, small case series, and studies unrelated to ACS populations were excluded. In parallel, a panel of 10 interventional cardiologists from major Lebanese institutions convened in Beirut in 2025. Experts critically appraised global trial data and contextualized recommendations within regional realities of patient risk profiles, drug accessibility, and healthcare infrastructure. Guidelines and pivotal trials endorse tailoring DAPT duration: shortened courses (1-3 months) with P2Y12 monotherapy in high-bleeding-risk patients, extended therapy beyond 12 months or dual-pathway inhibition in high-ischemic-risk patients, and preferential use of ticagrelor or prasugrel over clopidogrel in ACS. Expert consensus emphasized balancing bleeding and ischemic risks, incorporating validated risk scores, and adapting strategies to socioeconomic constraints in Lebanon and the wider MENA (Middle East and North Africa) region. By integrating global evidence with regional expert insights, this review provides a pragmatic framework for precision-based DAPT strategies in ACS, optimizing outcomes while minimizing harm.