To the Editor
The authors of the editorial published in the current issue of the Medical Research Journal stated that older patients are more liable to bleeding complications than younger ones due to the presence of clinical comorbidities that increase bleeding risk [1]. Therefore, the choice of an appropriate antiplatelet strategy is difficult to pursue. In the ELDERLY ACS 2 trial [2, 3] thrombotic events were lower during the first month of treatment in the low-dose prasugrel arm (5 mg once a day), whereas bleeding events were higher than in the standard dose clopidogrel (75 mg once a day) arm in the late phase after acute coronary syndrome (31–365 days) [3]. Considering the available evidence, the authors suggest that the de-escalation strategy appears suitable for patients in whom high bleeding risk is associated with high thrombotic risk [4].
Various de-escalation strategies of antiplatelet therapy have been and are currently being tested: switching from a stronger to a weaker P2Y12 inhibitor, switching from dual antiplatelet therapy to monotherapy, and reducing the dose of the P2Y12 inhibitor [5–9].
The ELECTRA-SIRIO 2 trial combines the strategies of P2Y12 inhibitor dose lowering and eliminating of aspirin [5], as it was hypothesized, that the reduction of ticagrelor maintenance dose to 60 mg b.i.d. 1 month after ACS, followed by aspirin withdrawal at 3 months after acute coronary syndrome will result in improved safety and tolerability of treatment with preserved anti-ischemic benefit [10, 11]. As the premature discontinuation of antiplatelet treatment is mainly related to bleeding, this approach may also be effective and safe in elderly patients [12, 13]. Monotherapy with low-dose ticagrelor would be expected to result in better adherence to treatment in real-life practice. Regardless of the expected higher adherence, special care is paid to keep patients on the study treatment, as termination of ticagrelor leaves the patients in the monotherapy arm unprotected against ischemic consequences, such as recurrent ACS [14–17]. All patients enrolled on the ELECTRA-SIRIO 2 trial undergo continuous multilevel educational and motivational interventions according to the Multilevel Educational and Motivational Intervention in Patients After Myocardial Infarction (MEDMOTION) project, including assessment with the Readiness for Hospital Discharge after Myocardial Infarction Scale at the end of hospitalization, with the Functioning in Chronic Illness Scale and the Adherence in Chronic Disease Scale during follow-ups [18–29].
The new approach of antiplatelet therapy de-escalation currently tested in the ELECTRA-SIRIO 2 trial is expected to decrease the incidence of clinically significant bleeding events during the first year after ACS, without a negative impact on the antithrombotic efficacy. In contrast to other de-escalation strategies, this approach does not require a platelet reactivity assessment, making this step-down of treatment easy and friendly for wide application in elderly patients.