Prolonged antithrombotic treatment after de-escalation of dual antiplatelet therapy in patients after acute coronary syndrome - which strategy should be applied? The ELECTRA-SIRIO 2 investigators standpoint.

De-escalation of dual antiplatelet (DAPT) intensity may be considered in patients with high risk of bleeding after acute coronary syndrome. Some high risk patients after de-escalation may require antithrombotic therapy prolonged over 12 months. With the current guideline recommended strategies, there are some doubts and uncertainties with respect to the transition period. Herein we discuss these issues more extensively. De-escalation of DAPT, intended to decrease bleeding risk, may be accomplished by switching to a drug with reduced antiplatelet effect (de-escalation by switching), by reducing the dose (de-escalation by dose reduction), or by removing an antiplatelet agent (de-escalation by discontinuation). The dilemma concerns patients who have undergone scheduled, early de-escalation of DAPT to monotherapy with a P2Y12 receptor inhibitor at standard dose, as in the TWILIGHT study. The dilemma is even greater in patients whose de-escalation consisted of both reduction in dose of one and discontinuation of the other antiplatelet agent. This strategy is currently being tested in the ELECTRA-SIRIO 2 study. When making a therapeutic decision in patients who meet the criteria for prolonged dual antithrombotic therapy we suggest considering the previously applied DAPT de-escalation strategy. In general, unless the risk of ischemic events has increased since prior de-escalation, there is no scientific rationale for escalating antithrombotic treatment in a patient previously de-escalated (through reduction or discontinuation). Regardless of the treatment strategy, its effectiveness depends on the patient's adherence to medical recommendations.