Vol 27, No 6 (2020)
Experts' Viewpoint
Published online: 2020-10-14

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Prolonged antithrombotic therapy in patients after acute coronary syndrome: A critical appraisal of current European Society of Cardiology guidelines

Jacek Kubica1, Piotr Adamski1, Piotr Niezgoda1, Dimitrios Alexopoulos2, Jolita Badarienė3, Andrzej Budaj4, Katarzyna Buszko, Dariusz Dudek56, Tomasz Fabiszak1, Mariusz Gąsior7, Robert Gil8, Diana A. Gorog9, Stefan Grajek10, Paul A. Gurbel11, Marcin Gruchała12, Miłosz J. Jaguszewski12, Stefan James13, Young-Hoon Jeong14, Bernd Jilma15, Jarosław D. Kasprzak16, Andrzej Kleinrok1718, Aldona Kubica19, Wiktor Kuliczkowski20, Jacek Legutko21, Maciej Lesiak9, Jolanta M. Siller-Matula2223, Klaudiusz Nadolny2425, Krzysztof Pstrągowski1, Salvatore Di Somma26, Giuseppe Specchia27, Janina Stępińska28, Udaya S. Tantry11, Agnieszka Tycińska29, Monica Verdoia30, Wojciech Wojakowski31, Eliano P. Navarese1
Pubmed: 33073857
Cardiol J 2020;27(6):661-676.


The increased risk of non-cardiovascular death in patients receiving clopidogrel or prasugrel in comparison with the placebo group in the Dual Antiplatelet Therapy (DAPT) trial in contrast to the decreased risk of cardiovascular death and all-cause death seen in patients treated with low-dose ticagrelor in the EU label population of the PEGASUS-TIMI 54 trial, resulted in inclusion in the 2020 ESC NSTE-ACS guidelines the recommendation for use of clopidogrel or prasugrel only if the patient is not eligible for treatment with ticagrelor.

The prevalence of the primary outcome composed of cardiovascular death, stroke, or myocardial infarction was lower in the low-dose rivaroxaban and acetylsalicylic acid (ASA) group than in the ASA-alone group in the COMPASS trial. Moreover, all-cause mortality and cardiovascular mortality rates were lower in the rivaroxaban-plus-ASA group.

Comparison of the PEGASUS-TIMI 54 and COMPASS trial patient characteristics clearly shows that each of these treatment strategies should be addressed at different groups of patients. A greater benefit in post-acute coronary syndrome (ACS) patients with a high risk of ischemic events and without high bleeding risk may be expected with ASA and ticagrelor 60 mg b.i.d. when the therapy is continued without interruption or with short interruption only after ACS. On the other hand, ASA and rivaroxaban 2.5 mg b.i.d. seems to be a better option when indications for dual antithrombotic therapy (DATT) appear after a longer time from ACS (more than 2 years) and/or from cessation of DAPT (more than 1 year) and in patients with multiple vascular bed atherosclerosis. Thus, both options of DATTs complement each other rather than compete, as can be presumed from the recommendations. However, a direct comparison between these strategies should be tested in future clinical trials.

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