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Korean Circ J. 2018 Oct;48(10):863-872. doi: 10.4070/kcj.2018.0255.

De-Escalation of P2Y12 Receptor Inhibitor Therapy after Acute Coronary Syndromes in Patients Undergoing Percutaneous Coronary Intervention.

Author information

1
Department of Cardiology, LMU Munich, Marchioninistraße 15, München, Germany.
2
DZHK (German Centre for Cardiovascular Research), Munich Heart Alliance, München, Germany. danny.kupka@med.uni-muenchen.de.
3
DZHK (German Centre for Cardiovascular Research), Munich Heart Alliance, München, Germany. dirk.sibbing@med.uni-muenchen.de, dirk@sibbing.net.

Abstract

Dual antiplatelet therapy (DAPT) - a combination of a P2Y₁₂ receptor inhibitor and aspirin - has revolutionized antithrombotic treatment. Potent P2Y₁₂ inhibitors such as prasugrel and ticagrelor exhibit a strong and more consistent platelet inhibition when compared to clopidogrel. Therefore, ticagrelor and prasugrel significantly reduce ischemic events, but at an expense of an increased bleeding risk in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). These observations have engaged intensive clinical research in alternative DAPT regimens to achieve sufficient platelet inhibition with an acceptable bleeding risk. Our review focusses on P2Y₁₂ receptor therapy de-escalation defined as a switch from a potent antiplatelet agent (ticagrelor or prasugrel) to clopidogrel. Recently, both unguided (platelet function testing independent) and guided (platelet function testing dependent) DAPT de-escalation strategies have been investigated in different clinical studies and both switching strategies could be possible options to prevent bleeding complications without increasing ischemic risk. In light of the still limited data currently available, future large-scale trials should accumulate more data on various DAPT de-escalation regimens with both ticagrelor and prasugrel in unguided and guided de-escalation approaches. In the current review we aim at summarizing and discussing the current evidence on this still emerging topic in the field of antiplatelet treatment.

KEYWORDS:

Acute coronary syndrome; DAPT de-escalation; P2Y₁₂ Inhibitors

Conflict of interest statement

Dr. Sibbing reports personal fees from Eli Lilly, personal fees from Pfizer, personal fees from Roche Diagnostics, personal fees from Daiichi Sankyo, personal fees from Astra Zeneca, personal fees from Bayer, personal fees from MSD, personal fees from Sanofi, outside the submitted work.

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