Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Caserta, Italy.
Division of Cardiology, AORN "Sant'anna E San Sebastiano", Caserta, Italy.
Expert Rev Cardiovasc Ther. 2023 Jul-Dec;21(7):545-551. doi: 10.1080/14779072.2023.2221851. Epub 2023 Jun 5.
Dual antiplatelet therapy (DAPT) with aspirin and a P2Y inhibitor is a cornerstone in the treatment of patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). Current international guidelines recommend the use of 12 months of DAPT with newer P2Y inhibitors (i.e. ticagrelor or prasugrel) as first-line therapy in this setting. However, intense and prolonged DAPT regimens are associated with an increased risk of bleeding, with relevant prognostic implications. Recently, a strategy of de-escalation of P2Y inhibitors has been proposed as an alternative to conventional DAPT to mitigate the risk of bleeding while preserving ischemic protection after ACS.
In this review, we summarize the available evidence on guided and unguided strategies for P2Y inhibitor de-escalation in patients with ACS undergoing PCI.
Among patients with ACS, guided and unguided de-escalation strategies are safe and effective for secondary cardiovascular prevention. Although the implementation of genetic and platelet function tests is of interest for treatment personalization, the routine use of guided de-escalation strategies seems impractical. In this context, unguided de-escalation approaches appear more attractive, convenient, and suitable for contemporary practice.
双联抗血小板治疗（DAPT）联合阿司匹林和 P2Y 抑制剂是经皮冠状动脉介入治疗（PCI）治疗急性冠脉综合征（ACS）患者的基石。目前的国际指南建议在这种情况下使用新型 P2Y 抑制剂（替格瑞洛或普拉格雷）进行 12 个月的 DAPT 作为一线治疗。然而，强化和延长的 DAPT 方案与出血风险增加相关，具有相关的预后意义。最近，提出了一种 P2Y 抑制剂降级策略作为传统 DAPT 的替代方案，以降低 ACS 后出血风险的同时保留缺血保护。
在这篇综述中，我们总结了关于接受 PCI 的 ACS 患者 P2Y 抑制剂降级的有指导和无指导策略的现有证据。
在 ACS 患者中，有指导和无指导的降级策略在二级心血管预防方面是安全有效的。尽管对基因和血小板功能检测的实施对治疗个体化很有意义，但常规使用有指导的降级策略似乎不切实际。在这种情况下，无指导的降级方法似乎更具吸引力、方便，并且适合当代实践。
