Abstract
The residual risk of patients surviving until 1 year after acute coronary syndromes (ACS) is still high, despite secondary prevention. The cornerstone of treatment of patients with ACS is dual antiplatelet therapy (DAPT) consisting of low-dose aspirin and a P2Y12 inhibitor (clopidogrel, prasugrel or ticagrelor) for 12 months, or less in those patients at higher risk for bleeding. To reduce the residual risk beyond 1 year in those patients not at high bleeding risk who tolerated DAPT and did not suffer an (ischaemic or bleeding) event would intuitively mean to prolong DAPT. However, prolonged DAPT always comes at the cost of more bleeding. Therefore, assessing both ischaemic and bleeding risk in these patients at 1 year after ACS is crucial. In addition, another antithrombotic treatment consisting of low-dose rivaroxaban combined with low-dose aspirin has been shown to reduce ischaemic events. In this review, we describe residual thrombotic risk at 1 year after ACS, evaluate the evidence for antithrombotic options beyond 1 year and provide a practical guide to determine which patients would benefit the most from these therapies.
Highlights
Over the past decades, the overall mortality of patients admitted with acute coronary syndrome (ACS) has decreased [1, 2]
This increase in non-cardiovascular death was shown in a meta-analysis of randomised controlled trials (RCTs) that compared short (3–12 months) to long (12–36 months) dual antiplatelet therapy (DAPT) in patients treated with drug-eluting stents (DES) [hazard ratio (HR) 0.67, 95% confidence interval (CI) 0.51–0.89] [16]
An interesting subanalysis of the PEGASUS-Thrombolysis in myocardial infarction (TIMI) 54 adds to the selection of patients that may benefit from extended-duration DAPT, demonstrating that patients who continue DAPT without interruption show a greater benefit than patients who restarted DAPT after an initial discontinuation 1 year post-myocardial infarction (MI) [17]
Summary
The overall mortality of patients admitted with acute coronary syndrome (ACS) has decreased [1, 2].
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