Acute Coronary Syndrome: What Is Safer, Antiaggregant Monotherapy or De-Escalation?

For several years it has been shown that 12-month dual antiplatelet therapy (DAPT) is mandatory for patients undergoing left main PCI for acute coronary syndrome (ACS). However, though this strategy does reduce thrombotic events and mortality, it also causes undesirable bleeding events followed by hospitalization and antiaggregation interruption for a period of time.

Síndromes coronarios agudos: ¿Qué es más seguro: monoterapia con antiagregante o De-Escalation?

A feasible strategy could be to interrupt one of the antiaggregants (be it aspirin -ASA- or P2Y12 inhibitor). The alternative could be to switch (De-Escalation) to a P2Y12 inhibitor of lower antiaggregation power (for example from prasugrel or ticagrelor to clopidogrel) or to reduce dosage.

This question remains unanswered.

This meta-analysis included 29 studies with 50602 patients, and it compared short duration antiaggregation (SHORT DAPT) vs. de-escalation.

Mean age was 63, there was an important number of women and a percentage of diabetics that ranged between 22% and 26%. There were no differences in all-cause mortality.

De-escalation reduced the risk of net adverse cardiovascular events (NACE) (RR: 0.87; 95% CI: 0.70-0.94) but increased the risk of major bleeding (RR: 1.54; 95% CI: 1.07-2.21).

De-Escalation showed >95% probability to prevent NACE, MI, stroke, stent-thrombosis, and minor bleeding. However, it showed a very high rate of major bleeding.

On the other hand, the SHORT DAPT approach showed better performance (>95%) in the prevention of major bleeding.

Conclusion

In patients with acute coronary syndrome undergoing PCI there were no differences in all-cause mortality between SHORT DAPT and De-Escalation. De-Escalation reduced NACE risk, while SHORT DAPT reduced the risk of major bleeding.

These data characterize 2 contemporary strategies to personalize the use of DAPT according to treatment goals and risk profile.