Antiplatelet Therapy and Anticoagulation before, during, and after Acute Coronary Syndrome

Abstract

Acute coronary syndrome (ACS) remains a major challenge in clinical practice, requiring rapid and effective antithrombotic treatment to mitigate adverse ischemic events while minimizing the risk of bleeding. In recent years, results from several clinical trials addressing this issue through various approaches have substantially improved the treatment landscape for patients presenting with ACS. The emergence of new, potent P2Y₁₂ inhibitors has significantly enhanced thrombotic risk reduction and different strategies for de-escalating and shortening dual antiplatelet therapy (DAPT) have demonstrated promising outcomes in reducing bleeding rates. Furthermore, data from ongoing trials focusing on novel therapeutic agents and investigating alternative treatment strategies to optimize outcomes for ACS patients are expected in the next few years. In this review, we summarize the current knowledge and emphasize the critical role of individualized treatment approaches tailored to patient-specific risk factors and individual clinical scenarios.

Keywords: acute coronary syndrome; anticoagulation; antiplatelet therapy; antithrombotic therapy; myocardial infarction.

Figure 2

Recommendations for anticoagulation in ACS, adapted from [2] Angio = angiography.

Figure 1

Bleeding risk criteria according to the Academic Research Consortium for High Bleeding Risk, adapted from [2]. AV-malformation = arteriovenous malformation, CKD = chronic kidney disease, and ICH = intracerebral hemorrhage.

Figure 3

Recommendations for shortening/de-escalation of DAPT, adapted from [2] HBR = high bleeding risk.

Figure 4

Recommendations for TAT/DAT, adapted from [2] DAT = dual antithrombotic therapy, TAT = triple antithrombotic therapy.