Egyptian Society of Cardiology national advisory statement revisiting antiplatelet therapy: insights from E. S. C. 2025 hot-line trials.

BACKGROUND

Antiplatelet therapy remains a cornerstone of the management of acute (ACS) and chronic coronary syndromes (CCS). The 2025 European Society of Cardiology (ESC) Congress presented several pivotal Hot-Line trials that challenge established paradigms regarding dual antiplatelet therapy (DAPT) duration, agent selection, and risk-based personalization.

PURPOSE: This national advisory statement synthesizes the clinical value and implications of 11 major antiplatelet trials presented at ESC 2025 and provides evidence-aligned, context-specific recommendations for cardiovascular practice in Egypt.

METHODS

A structured review of ESC 2025 Hot-Line antiplatelet trials was conducted. Evidence was appraised using a predefined grading framework, and national consensus was achieved through a multi-institutional expert panel using modified Delphi methodology. Recommendations were assigned Class of Recommendation and Level of Evidence according to ESC/ACC standards.

RESULTS

The trials addressed antiplatelet therapy in six clinical pathways: ACS, primary PCI in STEMI, cardiogenic shock, post-CABG, complex PCI, and chronic coronary syndrome requiring oral anticoagulation. Key findings include: (1) selective use of shortened DAPT in stabilized ACS; (2) a potential role for P2Y12 monotherapy after 1 month in low-risk, fully revascularized MI; (3) lack of benefit from ultra-early aspirin withdrawal; (4) no superiority of twice-daily aspirin in high-risk ACS; (5) twice-daily clopidogrel for 1 month as a possible alternative to ticagrelor in resource-limited STEMI settings; (6) superior platelet inhibition with intravenous cangrelor in cardiogenic shock without proven clinical superiority; (7) emerging evidence supporting shorter DAPT or aspirin monotherapy after CABG; (8) score-guided DAPT duration in complex PCI; and (9) confirmation that aspirin should not be added to oral anticoagulation in stable coronary disease.

CONCLUSION

The Egyptian Society of Cardiology supports a more individualized, risk-based approach to antiplatelet therapy, emphasizing ischemic-bleeding balance, stent technology, revascularization completeness, and national resource considerations. Recommendations should be interpreted cautiously given the preliminary nature of some ESC 2025 data.