Personalized Dual Antiplatelet Therapy in Acute Coronary Syndromes: Striking a Balance Between Bleeding and Thrombosis.

Content Provider	Europe PMC
Author	Shpigelman, Jonathan Proshkina, Anastasia Daly, Michael J. Cox, Dermot
Abstract	Purpose of ReviewDual antiplatelet therapy (DAPT)—aspirin in conjunction with a P2Y12 inhibitor—is the cornerstone of managing patients with acute coronary syndromes post-revascularization, but the clinical response is highly variable, with potentially devastating consequences. Herein, we review the mechanisms underpinning said variability and explore emerging approaches to normalizing therapeutic benefit.Recent Findings.The potent P2Y12 inhibitors, prasugrel and ticagrelor, exhibit minimal inter-individual variability, replacing clopidogrel in DAPT and achieving greater rates of therapeutic response. However, these benefits decline in later phases when bleeding risk begins to supersede that of ischemia. Guided de-escalation of P2Y12 inhibition as well as shortening DAPT duration have emerged as strategies that retain antithrombotic efficacy while reducing bleeding risk. Aspirin is the other component of DAPT but is also used in isolation for secondary prevention of thrombotic disease. In contrast to the P2Y12 inhibitors, genetic influences on aspirin non-response appear to be outweighed by a triad of clinical factors: non-adherence, enteric aspirin use, and inappropriate dosing according to bodyweight and BMI.SummaryMultiple de-escalation strategies for DAPT have been shown to mitigate bleeding risk, but it remains unclear which approach is ideal, necessitating head-to-head investigations to determine which exhibits the most favorable cost-to-benefit ratio. However, there is likely a role for more than one approach in clinical practice, depending on patient risk profile. Our approach to aspirin use is also in need of reassessment: strategies to improve adherence, avoidance of enteric aspirin in cardiac patients, and dose adjustment according to bodyweight and/or BMI are all likely to improve rates of therapeutic response. Moreover, platelet function testing may have a role in identifying patients expected to benefit from primary prophylactic aspirin.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11886-023-01892-9.
Related Links	https://europepmc.org/backend/ptpmcrender.fcgi?accid=PMC10307718&blobtype=pdf
ISSN	15233782
Journal	Current Cardiology Reports [Curr Cardiol Rep]
Volume Number	25
DOI	10.1007/s11886-023-01892-9
PubMed Central reference number	PMC10307718
Issue Number	7
PubMed reference number	37261665
e-ISSN	15343170
Language	English
Publisher	Springer US
Publisher Date	2023-06-01
Publisher Place	New York
Access Restriction	Open
Rights License	Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. © The Author(s) 2023
Subject Keyword	Precision medicine Personalized medicine Aspirin Dual antiplatelet therapy Percutaneous Coronary intervention Acute coronary syndrome
Content Type	Text
Resource Type	Article
Subject	Cardiology and Cardiovascular Medicine