REVIEW

Coronary

Individualising Antithrombotic Strategies for Acute

and Chronic Coronary Syndromes

Robert F Storey

Division of Clinical Medicine, School of Medicine and Population Health, University of Sheffield, Sheffield, UK

Abstract
For patients presenting with acute or chronic coronary syndromes, current guideline recommendations and expert consensus provide a range
of options for antithrombotic treatment. The European Society of Cardiology 2023 guidelines on the management of acute coronary syndrome
emphasise the need to assess the risk of both ischaemic events and bleeding. Those with high bleeding risk warrant particular consideration
of the duration and intensity of antithrombotic therapy combinations. A joint consensus of experts takes a similar approach, informed by two
network meta-analyses that appraised all available antithrombotic treatments within or after the 12 months following coronary revascularisation
and/or acute coronary syndrome and individual participant data from six trials. In this article, four case studies are used to illustrate how these
guidelines and expert consensus recommendations can be applied in clinical practice.

Keywords
Antithrombotic treatment, coronary artery disease, percutaneous coronary intervention, acute coronary syndrome, chronic coronary syndrome

Received: 22 November 2023 Accepted: 4 March 2024 Citation: Interventional Cardiology 2024;19:e07. DOI: https://doi.org/10.15420/icr.2023.44
Disclosure: RFS reports research grants and personal fees from AstraZeneca and Cytosorbents; and personal fees from Alfasigma, Boehringer Ingelheim/Lilly, Chiesi,
Daiichi Sankyo, Idorsia, Novartis, Novo Nordisk, Pfizer and PhaseBio.
Funding: The author acknowledges the financial support of AstraZeneca via an unrestricted educational grant.
Acknowledgements: Editorial support was provided by Radcliffe Cardiology.
Consent: Informed consent was obtained from patients to publish their data.
Correspondence: Robert F Storey, School of Medicine and Population Health, University of Sheffield, Barber House, 387 Glossop Rd, Sheffield S10 2HQ, UK.
E: [email protected]

Copyright: © The Author(s) 2024. This work is open access and is licensed under CC-BY-NC 4.0. Users may copy, redistribute and make derivative works for non-
commercial purposes, provided the original work is cited correctly.

Coronary artery disease (CAD) is associated with the risk of We use four case studies to highlight the considerations that must be
atherothrombotic events and warrants long-term antithrombotic made in deciding on the optimum antithrombotic strategy, based on the
therapy. The standard treatment for CAD patients who present with available guidelines. Given the choices available according to the ESC
acute coronary syndrome (ACS) or chronic coronary syndrome (CCS) guideline recommendations, we also draw on the strategies highlighted
includes single (SAPT) or dual antiplatelet therapy (DAPT), sometimes in in a recent European expert consensus statement, which used published
combination with oral anticoagulants (OACs).1,2 However, establishing network meta-analyses to rank competing antithrombotic strategies.4 In
the appropriate composition and duration of this standard treatment line with these, we support a tailored antithrombotic approach after
poses challenges in view of the associated risk of bleeding. Therefore, assessment of individual risk factors.
it is important to tailor the treatment according to individual ischaemic
and bleeding risks. Case Study 1: ACS with High Ischaemic
Risk and without High Bleeding Risk
European Society of Cardiology (ESC) guidelines have been revised to A male patient, aged 63 years, presented following a 1-hour episode of
identify patients who would benefit from either shortened or extended central chest pain. He had a history of hypertension and type 2 diabetes.
DAPT, or potent or less potent antithrombotic therapy.1,2 They recommend He was a current smoker and was taking a statin, a β-blocker and an oral
evaluation of both ischaemic and bleeding risk using a number of risk antihyperglycaemic. He had stage 3 chronic kidney disease (CKD) with
scores and tests that are available to facilitate this, while acknowledging estimated glomerular filtration rate (eGFR) of 55 ml/min/1.73 m2 at
that further work is required to explore any impact of the use of bleeding admission. Haemoglobin was normal at 146 g/l with normal mean
risk scores on clinical outcomes. Empirically, determining the optimal corpuscular volume (MCV). ECG showed an absence of ST segment
treatment is dependent upon assessing a comprehensive range of elevation. High-sensitivity troponin was initially mildly elevated and 1 hour
haemorrhagic and ischaemic risk factors while considering each patient’s later was above the threshold for rule-in of non-ST-elevation MI (NSTEMI).
clinical characteristics. The Academic Research Consortium (ARC) has Coronary angiography was scheduled for the following day, subject to cath
identified major and minor bleeding risk factors that can identify patients lab availability. This was performed 28 hours after presentation and
with high bleeding risk (HBR; Table 1).3 showed diffuse mild disease of the dominant right coronary artery (RCA)

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 Individualising Antithrombotic Strategies for ACS and CCS

Table 1: Major and Minor Criteria for High Bleeding Risk at the Time of Percutaneous Coronary Intervention

Major Minor
Age ≥75 years
Anticipated use of long-term oral anticoagulation*
Severe or end-stage CKD (eGFR <30 ml/min) Moderate CKD (eGFR 30–59 ml/min)
Haemoglobin <11 g/dl Haemoglobin 11–12.9 g/dl for men and 11–19 g/dl for women
Spontaneous bleeding requiring hospitalisation or transfusion in the past 6 months or Spontaneous bleeding requiring hospitalisation or transfusion within the past
at any time, if recurrent 12 months not meeting the major criterion
Moderate or severe baseline thrombocytopenia† (platelet count <100 × 109/l)
Chronic bleeding diathesis
Liver cirrhosis with portal hypertension
Long-term use of oral NSAIDs or steroids
Active malignancy‡ (excluding non-melanoma skin cancer) within the past 12 months
Previous spontaneous ICH (at any time) Any ischaemic stroke at any time not meeting the major criterion
Previous traumatic ICH within the past 12 months
Presence of a bAVM
Moderate or severe ischaemic stroke§ within the past 6 months
Non-deferrable major surgery on DAPT
Recent major surgery or major trauma within 30 days before PCI
*This excludes vascular protection doses. †Baseline thrombocytopenia is defined as thrombocytopenia before PCI. ‡Active malignancy is defined as diagnosis within 12 months and/or ongoing
requirement for treatment (including surgery, chemotherapy or radiotherapy). §National Institutes of Health Stroke Scale score ≥5. bAVM = brain arteriovenous malformation; CKD = chronic kidney
disease; DAPT = dual antiplatelet therapy; eGFR = estimated glomerular filtration rate; ICH = intracranial haemorrhage; NSAID = non-steroidal anti-inflammatory drug; PCI = percutaneous coronary
intervention. Source: Urban et al. 2019.3 Reproduced from Wolters Kluwer under a CC BY-NC-ND 4.0 License.

with a 50% stenosis at the origin of the posterior descending artery (PDA), 1. Aspirin is recommended for all patients without contraindications at
mild left main stem disease and a severe bifurcation stenosis (1,1,1) of the an initial oral LD of 150–300 mg (or 75–250 mg IV) and a
proximal left anterior descending (LAD) artery and first diagonal branch. He maintenance dose (MD) of 75–100 mg once daily for long-term
underwent percutaneous coronary intervention (PCI) with upfront two- treatment. Class 1, level of evidence a.
stent strategy using the mini-crush technique of both the diagonal artery 2. In all ACS patients, a P2Y12 receptor inhibitor is recommended
(2.5 mm × 15 mm everolimus-eluting stent [EES] with 2.75 mm × 10 mm non- in addition to aspirin, given as an initial oral LD followed by
compliant [NC] balloon) and the LAD artery (3.0 mm × 20 mm EES to mid- an MD for 12 months unless there is HBR. Class 1, level of
LAD and overlapping 3.5 mm × 24 mm EES postdilated with 3.5 mm× 12 mm evidence a.
NC balloon). Imaging confirmed achievement of good stent deployment. 3. Ticagrelor is recommended irrespective of the treatment strategy
(invasive or conservative) (180 mg LD, 90 mg twice-daily MD). Class 1,
Treatment of This Patient Based level of evidence b.
on Current Guidance 4. Pre-treatment with a P2Y12 receptor inhibitor may be considered in
This patient was treated with a loading dose (LD) of aspirin 300 mg. Given non-ST-segment elevation acute coronary syndrome (NSTE-ACS )
that coronary angiography could not be performed on the same day and patients who are not expected to undergo an early invasive
NSTEMI was diagnosed, he was treated with an LD of ticagrelor 180 mg strategy (<24 hours) and do not have HBR. Class 2b, level of
followed by 90 mg twice daily. It was uncertain whether coronary evidence c.
angiography would be performed within 24 hours and therefore 5. For patients with NSTE-ACS in whom early invasive angiography (i.e.
subcutaneous fondaparinux 2.5 mg was administered. Unfractionated within 24 hours) is not anticipated, fondaparinux is recommended.
heparin (UFH) 70 U/kg was administered at the time of PCI. After Class 1, level of evidence b.
undergoing PCI, the patient’s long-term ischaemic risk was considered 6. Routine use of a UFH bolus (weight-adjusted IV bolus during PCI of
high in view of multivessel CAD, type 2 diabetes and stage 3 CKD. His 70–100 IU/kg) is recommended in patients undergoing PCI. Class 1,
bleeding risk was not considered to be high due to the absence of any level of evidence c.
major ARC HBR characteristic and the presence of only one minor ARC 7. Adding a second antithrombotic agent to aspirin for extended
HBR characteristic, namely CKD with eGFR in the range 30–59 ml/ long-term secondary prevention should be considered in patients
min/1.73 m2 (two minor or one major ARC HBR criteria are required to with high ischaemic risk and without HBR. Class 2a, level of
indicate HBR). It was planned to continue low-dose aspirin and ticagrelor evidence a.
90 mg twice daily for 12 months followed by aspirin and ticagrelor 60 mg
twice daily in the long term thereafter, if tolerated, in view of the high The strategy of continuing long-term DAPT is also consistent with the
ischaemic risk with multiple ischaemic risk factors combined with the lack European expert consensus document that recommends long-term DAPT
of HBR. This decision was to be reviewed if he developed any HBR with aspirin and ticagrelor 60 mg twice daily in those with high ischaemic
conditions. risk and ‘very low bleeding risk’.4 However, the proportion of ACS patients
with this risk combination is small. An alternative strategy for long-term
This management is consistent with the ESC 2023 ACS guidelines, which dual antithrombotic therapy is the combination of aspirin with rivaroxaban
have the following recommendations:2 2.5 mg twice daily.

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 Individualising Antithrombotic Strategies for ACS and CCS

Influence of Timing of Coronary Angiography with eGFR in the range 30–59 ml/min/1.73 m2, prior ischaemic stroke not
on Guideline Recommendations meeting the criteria for a major HBR characteristic, and haemoglobin in
If coronary angiography had been performed on the same day as the range 110–129 g/l for a man. It was planned to continue low-dose
admission, then the 2023 ESC guidelines recommend against treatment aspirin and ticagrelor 90 mg twice daily for 3 months followed by cessation
with an oral P2Y12 inhibitor before angiography and, under these of aspirin and continuation of ticagrelor monotherapy (90 mg twice-daily)
circumstances, recommend that prasugrel should be considered in for a further 9 months, with a further decision to be made as to whether
preference to ticagrelor in ACS patients who proceed to PCI (class 2a, to continue ticagrelor in the long term or switch back to clopidogrel
level of evidence b), based predominantly on the ISAR-REACT 5 study monotherapy.
results.2 The evidence for and against these recommendations has
been reviewed in a previous debate.5 The guidelines also state that Implications of ESC 2023 ACS Guidelines
‘parenteral anticoagulation is recommended for all patients with ACS at Recommendations for This Case
the time of diagnosis’ and recommend that ‘for patients with NSTE-ACS The management of this patient was consistent with the following ESC
in whom early invasive angiography (i.e. within 24 h) is anticipated, 2023 ACS guidelines recommendations:2
enoxaparin should be considered as an alternative to UFH’ and
‘Intravenous enoxaparin at the time of PCI should be considered in 1. Aspirin is recommended for all patients without contraindications at
patients pre-treated with subcutaneous enoxaparin’. This parenteral an initial oral LD of 150–300 mg (or 75–250 mg IV) and an MD of
anticoagulation provides a bridge to coronary angiography when oral 75–100 mg once daily for long-term treatment. Class 1, level of
P2Y12 inhibition is withheld in NSTEMI patients. Consequently, it is evidence a.
implied by the ESC guidelines that the parenteral anticoagulation 2. Ticagrelor is recommended irrespective of the treatment strategy
strategy should be determined by the planned timing for PCI, with (invasive or conservative) (180 mg LD, 90 mg twice-daily MD). Class 1,
subcutaneous enoxaparin or IV UFH given in those planned for invasive level of evidence b.
angiography within 24 hours, whereas subcutaneous fondaparinux is 3. Drug-eluting stents are recommended in preference to bare metal
favoured when invasive angiography will be delayed >24 hours, under stents in all cases. Class 1, level of evidence a.
which circumstances pre-treatment with an oral P2Y12 inhibitor may also
be considered. However, the management was not consistent with the ESC 2023 ACS
guidelines in terms of treatment with an oral P2Y12 inhibitor prior to
Case Study 2: Acute Coronary coronary angiography given that this was performed less than 24 hours
Syndrome with High Bleeding Risk after the diagnosis of NSTEMI was made.2 Furthermore, the guidelines
A male patient, aged 68 years, presented following a 1-week history of recommend parenteral anticoagulation with UFH or, preferably,
new-onset exertional angina culminating in a 30-minute episode of enoxaparin rather than fondaparinux under these circumstances.
central chest pain at rest. He had a history of hypertension, However, it was not certain at the time of diagnosis whether coronary
hyperlipidaemia and minor ischaemic stroke 3 years earlier with no angiography would be performed within or more than 24 hours after
significant residual disability. He was a non-smoker and was taking diagnosis. The patient had HBR and the ESC 2023 ACS guidelines do not
ramipril, amlodipine, clopidogrel and a moderate-intensity statin provide any recommendation for oral P2Y12 inhibitor treatment before
regimen. He had stage 3 CKD with eGFR of 50 ml/min/1.73 m2 at coronary angiography in NSTE-ACS patients with HBR, therefore
admission. Haemoglobin was below the lower limit of normal for men at withholding oral P2Y12 inhibitor treatment for longer than 24 hours should
124 g/l with normal MCV. ECG showed T wave inversion in the inferior be considered an option in these patients.
leads and an absence of ST segment elevation. His high-sensitivity
troponin at admission was above the threshold for rule-in of NSTEMI. The ESC 2023 ACS guidelines provide a default recommendation for
Coronary angiography was scheduled for the following day. This was 12 months of DAPT in NSTE-ACS patients who do not have HBR but provide
performed 20 hours after presentation and showed normal left main support for a range of alternative strategies for shortening the duration of
stem, mild stenoses in the proximal and the mid LAD artery, normal non- DAPT in those with or without HBR, as follows (Figure 1):2
dominant circumflex artery, and severe disease with areas of moderate
calcification in the proximal to mid RCA with mild disease in the PDA. He 4. In patients who are event-free after 3–6 months of DAPT and
underwent PCI with 3.5 mm× 32 mm EES to the mid RCA and abutting who are not high ischaemic risk, SAPT (preferably with a P2Y12
4.0 mm × 28 mm EES to the proximal RCA, postdilated with 4.0 mm receptor inhibitor) should be considered. Class 2a, level of
× 15 mm NC balloon with excellent angiographic results. evidence a.
5. De-escalation of P2Y12 receptor inhibitor treatment (e.g. with a switch
Antithrombotic Treatment of This Patient from prasugrel/ticagrelor to clopidogrel) may be considered as an
This patient was treated with an LD of aspirin on admission. Given that alternative DAPT strategy to reduce bleeding risk. Class 2b, level of
coronary angiography could not be performed on the same day and there evidence a.
was a clear-cut diagnosis of NSTEMI, he was treated with an LD of 6. In HBR patients, aspirin or P2Y12 receptor inhibitor monotherapy
ticagrelor 180 mg followed by 90 mg twice daily instead of his prior after 1 month of DAPT may be considered. Class 2b, level of
clopidogrel treatment. It was uncertain whether coronary angiography evidence a.
would be performed within 24 hours and so subcutaneous fondaparinux
2.5 mg was administered. UFH 70 U/kg was administered at the time of Consequently, for this patient with HBR, either early switching from
PCI. After undergoing PCI, the patient’s long-term ischaemic risk was ticagrelor to clopidogrel may have been considered or cessation of
considered moderate in view of stage 3 CKD and age >65 years but aspirin may have been considered at 1 month rather than 3 months. The
without significant multivessel CAD. His bleeding risk was considered to guidelines also suggest that cessation of ticagrelor at 1 month may have
be high due to the presence of three minor ARC HBR characteristics: CKD been considered.

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 Individualising Antithrombotic Strategies for ACS and CCS

Figure 1: Alternative Antiplatelet Strategies to Reduce disease with moderate diffuse disease of a 2-mm-diameter first diagonal
Bleeding Risk in the First 12 Months after ACS. branch, severe stenosis in the mid vessel of the circumflex artery and
minor disease of the dominant RCA.
Abbreviated DAPT strategies DAPT de-escalation strategies
UFH was given as a bolus of a lower-than-standard dose of 60 U/kg
In HBR
patients
In HBR and
non-HBR patients
Potent P2Y12 inhibitor-based DAPT because a dose of apixaban had been given 6 hours previously. The
only
0
1 month
Aspirin + Prasugrel OR Aspirin + Ticagrelor circumflex stenosis was predilated with a 3.0 mm × 15 mm balloon
1
DAPT
3 followed by implantation of a 3.5 mm × 22 mm EES that was postdilated
months
DAPT
De-escalation with a 4.0 mm × 15 mm NC balloon with excellent angiographic results.
6
Change from potent P2Y12
Rather than giving any aspirin, clopidogrel was switched to ticagrelor
180 mg LD followed by 90 mg twice-daily in combination with apixaban
3 months
DAPT inhibitor to clopidogrel

5 mg twice-daily with a plan to switch back to clopidogrel after 1 month for

Aspirin + Clopidogrel
a further 5 months, followed by apixaban monotherapy in the long term.
Time (months)

6
Implications of the ESC 2023 ACS
P2Y12 inhibitor
or
Guidelines for This Case
aspirin monotherapy The management of this patient was consistent with the following
9 guideline recommendations:

1. During PCI, a UFH bolus is recommended in any of the following

circumstances: if the patient is on a non-vitamin K antagonist oral
12
anticoagulant (NOAC); if the international normalised ratio is <2.5 in
ACS = acute coronary syndrome; DAPT = dual antiplatelet therapy; ESC = European Society of vitamin K antagonist (VKA)-treated patients. Class 1, level of
Cardiology; HBR = high bleeding risk. Source: Byrne et al. 2023.2 Reproduced with permission
evidence c.
from Oxford University Press.
2. In patients requiring OACs, withdrawing antiplatelet therapy at
Implications of European Consensus 6 months while continuing OACs may be considered. Class 2b, level
Document for This Case of evidence b.
The European consensus document on antithrombotics makes 3. The use of ticagrelor or prasugrel as part of triple antithrombotic
recommendations for ACS patients undergoing PCI according to HBR therapy is not recommended. Class 3, level of evidence c.
status.4 For those without HBR, the default antiplatelet strategy is aspirin
and ticagrelor 90 mg twice-daily for 1–3 months, followed by ticagrelor The UFH dosing strategy was supported by the additional advice in the
monotherapy for up to 12 months post-ACS and then monotherapy with guidelines to perform PCI without interruption of OAC and, ‘in patients on
ticagrelor, clopidogrel or aspirin thereafter unless either (1) there is NOACs, regardless of the timing of the last administration of NOACs, add
concomitant polyvascular disease, in which case aspirin plus rivaroxaban low-dose parenteral anticoagulation (e.g. enoxaparin 0.5 mg/kg IV or UFH
2.5 mg twice-daily is the recommended default strategy, or (2) there is 60 IU/kg)’. Regarding the decision on duration of DAPT, requirement for
high ischaemic risk and very low bleeding risk, in which case aspirin plus long-term oral anticoagulation is a major ARC HBR criterion and the patient
ticagrelor 60 mg twice-daily is suggested although this may be a small also had a minor HBR criterion in view of stage 3 CKD. Despite concomitant
proportion of ACS patients. However, in those with HBR, such as in this diabetes, the extent of CAD was not felt to support dual antithrombotic
case, the default strategy is DAPT for only 1 month, consisting of aspirin therapy beyond 6 months in view of the technical success of the PCI
and either ticagrelor or clopidogrel, followed by SAPT thereafter with procedure and limited disease in the unstented major epicardial arteries.
ticagrelor, clopidogrel or aspirin. Consequently, the consensus document
proposes earlier cessation of DAPT (1 month) than was used in this case of The management was partially consistent with the following
HBR at 3 months post-PCI. recommendation given the high CHA2DS2-VASc score, although no triple
antithrombotic therapy was used and clopidogrel was switched to
Case Study 3: PCI for ACS with High ticagrelor, which is not the preferred strategy:
Bleeding Risk and Atrial Fibrillation
A female patient aged 72 years, with a history of stable angina, 4. As the default strategy for patients with AF and CHA2DS2-VASc score
hypertension, diabetes, permanent AF and borderline stage 3 CKD was ≥1 in men and ≥2 in women, after up to 1 week of triple
admitted with an episode of severe chest pain lasting 10 minutes. ECG antithrombotic therapy following the ACS event, dual antithrombotic
showed AF with satisfactory ventricular rate control and no evidence of therapy using a NOAC at the recommended dose for stroke
ischaemia. High-sensitivity troponin T remained within the normal range. prevention and a single oral antiplatelet agent (preferably
Creatinine was mildly elevated, with eGFR 58 ml/min/1.73 m2 indicating clopidogrel) for up to 12 months is recommended.
stage 3 CKD, and her haemoglobin was normal. Her CHA2DS2-VASc score
was 5. The patient was currently treated with apixaban 5 mg twice daily The 2023 guidelines no longer provide any recommendation about the
for thromboprophylaxis in view of the AF and additionally was receiving use of dual antithrombotic therapy with ticagrelor or prasugrel due to
bisoprolol, amlodipine, atorvastatin and metformin. A diagnosis of limited evidence.
unstable angina was made, and she was treated with an LD of clopidogrel
as SAPT in addition to apixaban prior to undergoing invasive coronary Given that angiography was performed 24 hours after admission, the
angiography. This was performed 24 hours after admission via the right management of the patient was borderline inconsistent with the following
radial artery and showed normal left main stem, mild proximal LAD artery recommendation:

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 Individualising Antithrombotic Strategies for ACS and CCS

Figure 2: Expert Consensus Overview

A Non-high bleeding risk

Acute coronary syndrome Chronic coronary syndrome

Treatment
indication

PCI CABG Medical treatment alone PCI CABG or medical treatment alone

Time

1 month

3 months

6 months

Up to
12 months
coronary syndrome
Post-acute chronic

B High bleeding risk

Acute coronary syndrome Chronic coronary syndrome

Treatment
indication

PCI CABG Medical treatment alone PCI CABG or medical treatment alone

Time

1 month

3 months

6 months

12 months
coronary syndrome
Post-acute chronic

= Aspirin = Clopidogrel = Prasugrel = Rivaroxaban = Ticagrelor

*For patients at high ischaemic risk and very low bleeding risk; §If the patient is not eligible for above shown treatment options. A = aspirin; C = clopidogrel; CABG = coronary artery bypass graft;
CAD = coronary artery disease; DAPT = dual antiplatelet therapy; DAT = Dual antithrombotic therapy; P = prasugrel; PCI = percutaneous coronary intervention; R = rivaroxaban; SAPT = single antiplatelet
therapy. T = ticagrelor. Source: Valgimigli et al. 2023.4 Reproduced with permission from Oxford University Press.

5. Routine pre-treatment with a P2Y12 receptor inhibitor in NSTE-ACS Case Study 4: Percutaneous Coronary
patients in whom coronary anatomy is not known and early invasive Intervention for CCS with High Bleeding Risk
management (<24 hours) is planned is not recommended. A female patient, aged 76 years, was admitted for elective diagnostic
angiography and possible PCI due to stable angina pectoris on mild
Implications of European Consensus exertion despite two anti-anginal drugs, bisoprolol and amlodipine. She
Document for This Case had a prior history of hypertension and a 22-pack-year history of smoking,
This document did not provide a consensus on antithrombotic which she had stopped 15 years earlier. She had stage 3 CKD with eGFR
management of patients with a baseline indication for OACs, such as AF. of 42 ml/min/1.73 m2 and her haemoglobin was 108 g/l, which had

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 Individualising Antithrombotic Strategies for ACS and CCS

remained stable during treatment with aspirin. Her other cardiovascular Given that this patient had one major and two minor ARC HBR criteria,
medication consisted of atorvastatin, ramipril and indapamide. attenuating the duration of clopidogrel to 1 month could have been
Echocardiography prior to admission had demonstrated mild left considered, according to the following ESC 2019 CCS guidelines
ventricular systolic dysfunction with moderate apical hypokinesia. recommendation:

Coronary angiography demonstrated mild left main stem disease, severe 4. Clopidogrel 75 mg daily following appropriate loading (e.g. 600 mg
stenosis in the mid LAD artery involving a moderate-sized second diagonal or >5 days of maintenance therapy) may be considered for 1 month in
branch, a 50% stenosis in the proximal circumflex which was a small non- patients with very high risk of life-threatening bleeding. Class 2b,
dominant vessel, and mild diffuse disease in the RCA. The diagonal artery level of evidence c.
was treated initially with 2.25 mm × 12 mm balloon dilatation and the mid-
LAD stenosis was treated with a 2.75 mm × 18 mm EES, achieving a good The European consensus document provides recommendations for CCS
angiographic result to the LAD but compromise to the origin of the patients undergoing PCI according to the presence or absence of HBR as
diagonal artery, which was then treated with a 2.5 mm × 12 mm EES using well as according to whether or not there is a history of prior MI.4 For CCS
the T and small protrusion (TAP) technique. patients undergoing PCI without prior MI, the consensus proposes default
approaches in those without HBR of either 6 months DAPT with aspirin
Antithrombotic Therapy Based and clopidogrel followed by SAPT (consisting of aspirin or clopidogrel
on Current Guidance monotherapy), or 1–3 months DAPT with aspirin and clopidogrel or
This patient was deemed to have HBR based on both one major ARC HBR ticagrelor followed by SAPT with any one of these three; for those with
criterion (haemoglobin <110 g/l) and two minor ARC HBR criteria (eGFR in HBR, the consensus proposes 1 month of DAPT with aspirin and either
the range 30–59 ml/min/1.73 m2; age ≥75 years). The patient continued clopidogrel or ticagrelor followed by long-term monotherapy with
low-dose aspirin in the long-term and received an LD of clopidogrel clopidogrel, ticagrelor or aspirin (Figure 2).
600 mg before proceeding with PCI, followed by an MD of clopidogrel
75 mg once-daily, which was discontinued at 3 months due to the HBR. Conclusion
Patients with ACS or CCS present with a diverse range of clinical
This management is consistent with the following ESC 2019 CCS guidelines features, often including a number of comorbidities and risk factors.
recommendations:1 Managing these patients requires individualisation of the antithrombotic
treatment strategy. Recent evidence supports much greater scrutiny of
1. Aspirin 75–100 mg daily is recommended following stenting. Class 1, bleeding risk, identifying patients with HBR who warrant attenuated
level of evidence a. duration of DAPT compared with historical recommendations.
2. Clopidogrel 75 mg daily following appropriate loading (e.g. 600 mg Consequently the default strategy of 12 months of DAPT for ACS and
or >5 days of maintenance therapy) is recommended, in addition to 6 months of DAPT following PCI for CCS has been replaced with more
aspirin, for 6 months following coronary stenting, irrespective of stent nuanced management according to assessment of ischaemic risk and
type, unless a shorter duration (1–3 months) is indicated due to risk HBR status. The ESC 2019 CCS guidelines and 2023 ACS guidelines
or the occurrence of life-threatening bleeding. Class 1, level of provide many recommendations on individualisation of antiplatelet
evidence a. strategy and these are complemented by the European consensus
3. Clopidogrel 75 mg daily following appropriate loading (e.g. 600 mg document that draws on two companion network meta-analyses and
or >5 days of maintenance therapy) should be considered for individual patient data pooled from multiple trials in order to rank the
3 months in patients with a higher risk of life-threatening bleeding. available options and point towards preferred strategies in different
Class 2a, level of evidence a. scenarios.1,2,4,6

1. Knuuti J, Wijns W, Saraste A, et al. 2019 ESC guidelines for PMID: 31116032. 6. Navarese EP, Landi A, Oliva A, et al. Within and beyond
the diagnosis and management of chronic coronary 4. Valgimigli M, Aboyans V, Angiolillo D, et al. Antithrombotic 12-month efficacy and safety of antithrombotic strategies in
syndromes. Eur Heart J 2020;41:407–77. https://doi. treatment strategies in patients with established coronary patients with established coronary artery disease: two
org/10.1093/eurheartj/ehz425; PMID: 31504439. atherosclerotic disease. Eur Heart J Cardiovasc Pharmacother companion network meta-analyses of the 2022 joint clinical
2. Byrne RA, Rossello X, Coughlan JJ, et al. 2023 ESC 2023;9:462–96. https://doi.org/10.1093/ehjcvp/pvad032; consensus statement of the European Association of
guidelines for the management of acute coronary PMID: 37120728. Percutaneous Cardiovascular Interventions (EAPCI),
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