Approaches to de-escalation of antiplatelet treatment in stabilized post-myocardial infarction patients with high ischemic risk

Introduction: In patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI), dual antiplatelet therapy (DAPT) with a potent P2Y 12 inhibitor is normally recommended for 12 months. However, the greatest anti-ischemic benefit of DAPT occurs early, while most excess bleeding events occur during chronic treatment. De-escalation of DAPT is an emerging treatment strategy for ACS patients. Areas covered: This review critically evaluates the evidence for de-escalation based on clinical judgment (i.e. unguided) or guided by either platelet function testing or CYP2C19 genotyping. Ongoing trials and research directions are also discussed. Expert opinion: De-escalation of antiplatelet therapy represents a viable therapeutic alternative to standard DAPT for patients after an ACS, aimed at providing a good balance between the risks of thrombosis and bleeding. It is not clear if this approach is better with or without guidance by platelet function testing or genotyping. Also, the benefit versus short DAPT is uncertain. Current guidelines support the de-escalation of DAPT for selected patients who are unsuitable for potent platelet inhibition, a cohort of patients that was not specifically represented in landmark trials of de-escalation. More studies are needed to define the optimal candidates for this strategy.