De-Escalation of Dual Antiplatelet Therapy in Patients With Acute Coronary Syndromes

Satoshi Shoji, Toshiki Kuno, Tomohiro Fujisaki, Hisato Takagi, Alexandros Briasoulis, Pierre Deharo, Thomas Cuisset, Azeem Latib, Shun Kohsaka

Research output: Contribution to journalArticlepeer-review

46 Scopus citations


Background: Balancing the effects of dual antiplatelet therapy (DAPT) in the era of potent P2Y12 inhibitors has become a cornerstone of acute coronary syndrome (ACS) management. Recent randomized controlled trials (RCTs) have investigated DAPT de-escalation to decrease the risk of bleeding outcomes. Objectives: The aim of this study was 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. Methods: MEDLINE and EMBASE were searched through January 2021 for RCTs investigating the efficacy and safety of DAPT in patients with ACS, and a network meta-analysis was conducted. The primary efficacy outcome was a composite of cardiovascular death, myocardial infarction, and stroke. The primary bleeding outcome was trial-defined major or minor bleeding. Results: Our search identified 15 eligible RCTs, including 55,798 patients with ACS. De-escalation therapy was associated with reduced risk of primary bleeding outcomes (HR: 0.48 [95% CI: 0.30-0.77] vs clopidogrel; HR: 0.32 [95% CI: 0.20-0.52] vs ticagrelor; HR: 0.36 [95% CI: 0.24-0.55] vs standard-dose prasugrel; and HR: 0.40 [95% CI: 0.22-0.75] vs low-dose prasugrel) without negatively affecting primary efficacy outcomes. There were no significant differences in ischemic or bleeding outcomes between de-escalation to clopidogrel or low-dose prasugrel. Conclusions: Compared with other established uses of DAPT, de-escalation was the most effective strategy for ACS treatment, resulting in fewer bleeding events without increasing ischemic events.

Original languageEnglish
Pages (from-to)763-777
Number of pages15
JournalJournal of the American College of Cardiology
Issue number8
StatePublished - 24 Aug 2021


  • clopidogrel
  • de-escalation
  • low-dose
  • network meta-analysis
  • prasugrel
  • systematic review
  • ticagrelor


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