Expert opinion. Double antiplatelet therapy after ACS: "de-escalation"

In medical practice, cases in which patients with acute coronary syndrome (ACS) and received a combination of acetylsalicylic acid (ASA) with prasugrel or ticagrelor are often used, a combination of ASA with clopidogrel is started. This transition from more active platelet-derived P2Y12 blockers to less active clopidogrel has been termed "de-escalation."

The possibility of "de-escalation" is considered in documents prepared by various expert groups. Among them, an updated version of the recommendations of the European Society of Cardiology and the European Association of Cardio Thoracic Surgeons for double antiplatelet therapy for coronary heart disease, where a similar transition is proposed to be discussed with side effects or intolerance of prasugrel / ticagrelor. There is also an agreement of experts from Europe and the USA, in which practical approaches to the replacement of the P2Y12 blocker of the platelet receptor are analyzed in detail. However, it should be borne in mind that these proposals are basically based on common sense and representations of the pharmacological properties of various P2Y12 receptor blockers of the platelet, while the evidence base for "de-escalation" is small.

Thus, in a recently published prospective clinical study TOPIC, most closely approximated to everyday medical practice, the transition from prasugrel or ticagrelor to clopidogrel within a month after coronary stenting in patients with acute coronary syndrome was not accompanied by an increase in the incidence of ischemic complications and gave a gain in safety decrease in the frequency of clinically significant bleeding). However, the limitations of this clinical trial (a small number of patients, the open nature of the study) do not give grounds for changing existing approaches to the choice of the composition of double antiplatelet therapy after ACS. In addition, TOPIC studies contradict the results of large controlled clinical trials of TRITON-TIMI 38 and PLATO, which demonstrated a positive effect with prolonged use of a combination of ASA with prasugrel or ticagrelor in comparison with its combination with clopidogrel. Obviously, before the resolution of these contradictions and the emergence of new facts, it is premature to consider the expediency of widespread use of "de-escalation". However, if a particular patient is talking about early termination of double antiplatelet therapy after ACS, switching from prasugrel or ticagrelor to clopidogrel is a more attractive alternative.


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Igor S. Yavelov, MD, PhD