Consequences of escalation and de-escalation of double antiplatelet therapy in patients with acute coronary syndrome in real clinical practice

In recent years, the problem of P2Y12 inhibitor switching, called escalation and deescalation of double antiplatelet therapy (DAPT), in patients with acute coronary syndrome (ACS) has been the subject of active discussion.

Aim. To assess the frequency and clinical consequences of transition from ticagrelor to clopidogrel and from clopidogrel to ticagrelor in real clinical practice in patients with ACS.

Material and methods. Three hundred eight patients with ACS were included in the open, observational study. 121 patients (39,3%) receive conservative treatment, and 187 (60,7%) had invasive management tactics — percutaneous coronary interventions (PCI). In the group of conservative treatment switching from ticagrelor to clopidogrel and back was performed in 7 (5,8%) and 12 (9,9%) patients, respectively. In the second group switching from ticagrelor to clopidogrel and back were observed in 42 (34,7%) and 41 (33,9%) patients, respectively. Switching from one P2Y12 inhibitor to another occurred on 2-4 months from the beginning of therapy. The frequency of the following adverse events was chosen as the primary end point: death, re-infarction, re-hospitalization due to the development of chest pain syndrome, the need for coronary angiography or PCI.

Results. In both groups of patients with ACS, the best survival was shown by patients who had an escalation of DAPT. In turn, during de-escalation, a significant decrease in survival cases was observed with the onset of one of the endpoint events (RR 2,88 with 95% CI 1,23-6,78; p<0,02). Conclusion. The study indicates a high frequency of de-escalation and escalation of DAPT, carried out in the outpatient management of patients undergoing ACS. There is a need of additional issue-related studies.

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