Toyota Toshiaki, Watanabe Hirotoshi, Kim Kitae, Furukawa Yutaka, Kimura Takeshi
Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan.
Department of Cardiovascular Medicine, Hirakata Kohsai Hospital, Hirakata, Osaka, Japan.
J Neuroendovasc Ther. 2025;19(1). doi: 10.5797/jnet.ra.2024-0102. Epub 2025 May 27.
Acute coronary syndrome (ACS) encompasses a spectrum of cardiovascular emergencies, including unstable angina and myocardial infarction, that require immediate and effective management to reduce morbidity and mortality. Antithrombotic therapy, including antiplatelet and anticoagulant medications, is fundamental in ACS management. We sought to organize the current status of antithrombotic management of ACS, including the concept of high bleeding risk (HBR), in line with the clinical diagnostic flow. ACS is an ever-changing condition; therefore, its diagnosis and treatment are conducted in parallel. While primarily a coronary artery disease, the diagnosis of ACS also includes conditions such as myocardial infarction with nonobstructive coronary arteries as a working diagnosis. This review collates the mechanisms and classification of ACS, showing the diagnostic flow and the antithrombotic agents used at each stage. It discusses strategies for dual antiplatelet therapy (DAPT) duration and de-escalation in patients undergoing percutaneous coronary intervention and addresses the management of patients requiring oral anticoagulation alongside antiplatelet therapy, highlighting the shift toward dual therapy to reduce bleeding risk. Antithrombotic agents are key treatments for ACS, with various available options. Their mechanisms and the approved dosing regimens differ regionally, especially between Japan and other countries. This review synthesizes the regional availability of each agent and compares the latest recommendations from Japanese and international guidelines for ACS management. The field of antithrombotic therapy in ACS is dynamic, influenced by the findings of ongoing clinical trials and emerging evidence. Key considerations include balancing antithrombotic benefits against bleeding risks, particularly in patients with HBR. Recent studies have explored shorter DAPT durations and novel antithrombotic agents, offering new insights for diverse patient populations. In this review, we provide a comprehensive comparison of guidelines and insights from the neuro-interventional field to assist clinicians in making informed decisions regarding ACS management. As ACS management evolves, continued international, cross-sectional collaboration and research are essential to refine guidelines and improve clinical practice.
急性冠状动脉综合征（ACS）涵盖一系列心血管急症，包括不稳定型心绞痛和心肌梗死，这些急症需要立即进行有效治疗以降低发病率和死亡率。抗栓治疗，包括抗血小板和抗凝药物，是ACS治疗的基础。我们试图根据临床诊断流程梳理ACS抗栓治疗的现状，包括高出血风险（HBR）的概念。ACS是一种不断变化的疾病；因此，其诊断和治疗是并行进行的。虽然ACS主要是一种冠状动脉疾病，但其诊断还包括如非阻塞性冠状动脉心肌梗死等情况作为工作诊断。本综述整理了ACS的机制和分类，展示了诊断流程以及各阶段使用的抗栓药物。它讨论了接受经皮冠状动脉介入治疗患者的双联抗血小板治疗（DAPT）持续时间和降阶梯策略，并探讨了在抗血小板治疗的同时需要口服抗凝治疗的患者的管理，强调了向双联治疗转变以降低出血风险。抗栓药物是ACS的关键治疗方法，有多种可用选择。它们的作用机制和批准的给药方案因地区而异，特别是在日本和其他国家之间。本综述综合了每种药物在各地区的可用性，并比较了日本和国际ACS管理指南的最新建议。ACS抗栓治疗领域是动态的，受到正在进行的临床试验结果和新出现证据的影响。关键考虑因素包括平衡抗栓益处与出血风险，特别是在HBR患者中。最近的研究探索了更短的DAPT持续时间和新型抗栓药物，为不同患者群体提供了新的见解。在本综述中，我们对指南进行了全面比较，并提供了神经介入领域的见解，以帮助临床医生就ACS管理做出明智的决策。随着ACS管理的不断发展，持续的国际、横断面合作和研究对于完善指南和改善临床实践至关重要。
