 ha sido el tratamiento estándar para el manejo de pacientes con SCA sometidos a angioplastia coronaria, existe una creciente conciencia sobre la necesidad de adoptar un enfoque más centrado en el paciente, que logre equilibrar la protección isquémica que ofrece la DAPT con el riesgo de complicaciones hemorrágicas asociadas.){kind=link}
While dual antiplatelet therapy (DAPT) has long been the standard treatment for managing patients with acute coronary syndrome (ACS) undergoing coronary angioplasty, there is growing awareness of the need for a more patient-centered approach that will balance the ischemic protection offered by DAPT with the risk of bleeding complications.
4D-ACS, a randomized clinical trial conducted in Korea, included 656 East Asian patients with ACS, randomized 1:1 to receiving either one month DAPT with 100 mg aspirin and 10 mg prasugrel (with 5 mg reduced dose of prasugrel for ≥75 year-old or <60 kg patients), followed by prasugrel 5 mg monotherapy (DAPT-1M group); or the conventional 12-month DAPT regimen with aspirin and 5 mg prasugrel (DAPT-12M group). This study is one of the first to evaluate strategies for shortening or de-escalating DAPT.
Primary endpoint was net adverse clinical events (NACE) at 12 months, defined as a composite of death, non-fatal myocardial infarction, stroke, ischemia-driven target vessel revascularization, and Bleeding Academic Research Consortium (BARC) type 2–5 bleeding.
At 12 months, NACE rate resulted 4.9% among DAPT-1M patients and 8.8% in the DAPT-12M group, meeting the criteria for both non-inferiority and superiority. The incidence of major bleeding was 0.6% vs. 4.6% (HR 0.13; p = 0.007) for DAPT-1M and DAPT-12M groups, respectively. Ischemic events remained comparable between the two.
Conclusion
The 4D-ACS showed a de-escalation protocol of one-month DAPT followed by low-dose prasugrel monotherapy is safe and feasible in ACS patients treated with drug-eluting stents (DES). This strategy improved safety by significantly reducing bleeding risk with no compromise of ischemic protection. Short DAPT followed by monotherapy represents a viable therapeutic alternative, which sets apart from the rigid paradigm of prolonged DAPT toward a patient-centered, risk-adapted model.
Reference: Jang Y, Park S-D, Lee JP, et al EuroPCR 2025.
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