De-escalation of DAPT effective strategy for treatment of acute coronary syndrome: JACC

USA: According to a recent study in the Journal of the American College of Cardiology (JACC), de-escalation is the most effective strategy for ACS treatment compared to other established uses of dual antiplatelet therapy (DAPT). De-escalation results in fewer bleeding events without increasing ischemic events. 

DAPT with aspirin and an oral P2Y12 receptor inhibitor (clopidogrel, prasugrel, or ticagrelor) is the cornerstone of management of patients with acute coronary syndrome or undergoing percutaneous coronary intervention (PCI). Current international guidelines recommend primarily at least 12 months of therapy with DAPT with high potency P2Y12 inhibitor (ticagrelor or prasugrel), except in patients with high or very high bleeding risk. De-escalation is defined as switching from prasugrel or ticagrelor to clopidogrel as a strategy to reduce bleeding risk, commonly occurring in clinical practice.

It was found in the study that after 12-months of randomization, the de-escalation group met the criteria for superiority with respect to the composite primary outcome of cardiovascular mortality, myocardial infarction, stroke, or bleeding. Further. Type 2, 3, or 5 bleeding was significantly less frequent in the clopidogrel group (3.0%) compared to the ticagrelor group (5.6%). 

Satoshi Shoji and colleagues conducted the study with an aim to compare the efficacy and safety outcomes of various DAPT strategies in patients with ACS, including de-escalation from a potent P2Y12 inhibitor to clopidogrel or low-dose prasugrel.