Complexity of Antiplatelet Therapy in Coronary Artery Disease Patients

Pierre Sabouret; Michael P. Savage; David Fischman; Francesco Costa


Am J Cardiovasc Drugs. 2021;21(1):21-34. 

In This Article


The choice of antiplatelet therapy remains challenging. Indeed, coronary patients often combine high ischemic and hemorrhagic risk, which explains why the risk–benefit balance is often difficult to evaluate in practice. The novel aspects of guidelines associate early administration of clopidogrel or ticagrelor for NSTEMI patients, the use of prasugrel or ticagrelor over clopidogrel for stable CAD with complex PCI, DAPT duration using risk scores (DAPT and PRECISE DAPT), the widespread prescription of PPIs in combination with DAPT, a practical guide to switch agents if necessary, second-generation DESs as the preferred choice for PCI, and the combination of antiplatelet agents and low dose of DOACs in specific populations. A shorter, 3-month duration of ACS followed by monotherapy with ticagrelor for 12 months, or, at the opposite, a long-term combination with low doses of aspirin and rivaroxaban, represent potential changes in the next guidelines. Despite many studies being conducted during the last years, there are still remaining questions on the optimal antithrombotic regimen after 1 year post ACS, the usefulness of pharmacogenetic testing to guide treatment, and the risk–benefits of a de-escalation of P2Y12 inhibitors. These fields need further research to optimize patient management.