Despite improvements in the secondary prevention of atherothrombosis in patients with coronary artery disease during the past decade, it is estimated that approximately 19 million people annually die from cardiovascular diseases worldwide. Atherothrombosis remains the core pathobiology of acute complications including myocardial infarction (MI), and therefore, antithrombotic therapy plays a pivotal role in the strategies for major adverse cardiovascular event (MACE) prevention. Unlike early antithrombotic management after acute coronary syndrome, less evidence is available on long-term antithrombotic therapy in patients with chronic coronary syndrome (CCS). In addition, greater recognition of the impact of bleeding complications of such therapies has led to a more complex and personalized approach to their application. The purpose of this article is to review the available evidence on long-term antithrombotic therapy in patients with CCS including those with high-risk characteristics such as prior MI or polyvascular disease.

A comprehensive literature review was performed in major databases including PubMed, Embase, and the Cochrane Library. The main focus of this narrative review was on available data from guidelines, meta-analysis, randomized controlled trials, and observational studies that assessed the efficacy and safety profile of long-term antithrombotic therapy in patients with CCS.

Several studies suggest that long-term antithrombotic therapy is effective in reducing the risk of recurrent MACEs in patients with CCS. Current clinical guidelines recommend single antiplatelet therapy with aspirin as a first-line long-term strategy for patients without indication for oral anticoagulation. However, novel approaches focused on P2Y12 inhibitor monotherapy are emerging. More intensive antithrombotic strategies including long-term dual antiplatelet therapy and dual pathway inhibition further reduce ischemic risk but at the cost of increased bleeding.

This review highlights the importance of close monitoring and regular reassessment of the risk-benefit balance of antithrombotic therapy in patients with CCS. Overall, long-term antithrombotic therapy with either single antiplatelet therapy or dual antiplatelet therapy/dual pathway inhibition is effective in reducing the risk of MACEs in patients with CCS. The choice of antithrombotic therapy should be individualized based on the patient's clinical profile, particularly for thrombohemorrhagic risk. Future research should focus on identifying the optimal antithrombotic regimen for specific subgroups of patients with prior MI particularly for those with high bleeding risk.

Stroke is a leading cause of death and disability worldwide. Approximately one-third of patients with stroke experienced a second stroke. This study investigates the predictive value of machine learning (ML) algorithms for recurrent stroke.

This study was prepared according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. PubMed, Scopus, Embase, and Web of Science (WOS) were searched until January 1, 2024. The quality assessment of studies was conducted using the QUADAS-2 tool. The diagnostic meta-analysis was conducted to calculate the pooled sensitivity, specificity, diagnostic accuracy, positive and negative diagnostic likelihood ratio (DLR), diagnostic accuracy, diagnostic odds ratio (DOR), and area under of the curve (AUC) by the MIDAS package in STATA V.17.

Twelve studies, comprising 24,350 individuals, were included. The meta-analysis revealed a sensitivity of 71% (95% CI 0.64-0.78) and a specificity of 88% (95% confidence interval (CI) 0.76-0.95). Positive and negative DLR were 5.93 (95% CI 3.05-11.55) and 0.33 (95% CI 0.28-0.39), respectively. The diagnostic accuracy and DOR was 2.89 (95% CI 2.32-3.46) and 18.04 (95% CI 10.21-31.87), respectively. The summary ROC curve indicated an AUC of 0.82 (95% CI 0.78-0.85).

ML demonstrates promise in predicting recurrent strokes, with moderate to high sensitivity and specificity. However, the high heterogeneity observed underscores the need for standardized approaches and further research to enhance the reliability and generalizability of these models. ML-based recurrent stroke prediction can potentially augment clinical decision-making and improve patient outcomes by identifying high-risk patients.

Peripheral arterial disease (PAD) affects millions of people worldwide. It is a progressive atherosclerotic condition that ranges from asymptomatic disease to severe manifestations such as chronic limb-threatening ischemia and acute limb ischemia. Major risk factors-diabetes mellitus, smoking, hypertension, and hypercholesterolemia-contribute to its pathogenesis by promoting oxidative stress, endothelial dysfunction, and platelet activation. Optimizing antiplatelet and anticoagulant therapy is essential to reducing major adverse cardiovascular events and major adverse limb events. Aspirin and clopidogrel remain standard therapies, but recent trials such as COMPASS and VOYAGER PAD highlight the benefits of combination therapy with low-dose rivaroxaban and aspirin, particularly postrevascularization. Dual antiplatelet therapy is beneficial in select patients, but bleeding risks necessitate individualized treatment approaches. Emerging therapies and procedural advancements offer promising options for high-risk populations, such as those with diabetes, chronic kidney disease, and frailty. This review presents a multidisciplinary approach to PAD management, emphasizing risk stratification and personalized pharmacologic strategies that balance ischemic event prevention with bleeding risk mitigation.

Low-dose aspirin has been the cornerstone of single and dual antiplatelet treatment across the cardiovascular risk continuum. It has a well-established efficacy and safety profile, supported by large-scale, placebo-controlled trials as well as long-standing clinical experience. Low-dose aspirin has the highest recommendations in international guidelines for patients with chronic coronary syndromes (CCS), including a lifelong recommendation in patients post vascular interventions and those without prior myocardial infarction or revascularization but with evidence of significant obstructive coronary artery disease.P2Y12 inhibitors - including clopidogrel, ticagrelor, and prasugrel - have recently been explored as an alternatives to low-dose aspirin in patients with CCS, with various trials comparing their efficacy and safety to aspirin.

We reviewed the pharmacodynamic and pharmacokinetic properties of low-dose aspirin and P2Y12 inhibitors, data from trials and meta-analyses, and factors that may influence adherence to therapy.

The usefulness and generalizability of the current data on P2Y12 inhibitor monotherapy are limited by a lack of large-scale, multicenter, multiethnic trials. Furthermore, P2Y12 inhibitors lack the evidence for long-term safety and efficacy that are associated with low-dose aspirin. We feel that low-dose aspirin remains a cornerstone therapy in the management of patients with CCS.

This trial examined the feasibility of a future trial of remotely supervised exercise (RSE) versus self-directed exercise (SDE) for stable claudication.

Randomized, single center, assessor blind, feasibility trial. In the intervention arm patients received fortnightly video or telephone calls from a physiotherapist with a tailored exercise prescription and review of progress with the aim of a minimum of 120 min of leg exercise per week. In the comparator arm, patients were asked to do this themselves. Both groups had an electronic walking log which was inspected at 3 and 6 months. The primary endpoint was maximum walking distance recorded by a blinded assessor. As this was a feasibility study the randomization target was 40 patients.

44 patients were randomized over a 2 year period. The eligibility rate was 57% of those screened. The participation rate was 100% of those eligible. The withdrawal rate was 27% of those randomized. Maximum walking distance improved, on average, by +369m in the remotely supervised group and by +322m in the SDE group. Quality of life gains were similar in both arms.

A large randomized controlled trial comparing RSE with SDE would be difficult using this protocol, because of the high withdrawal rate and small treatment effect.

Peripheral artery disease (PAD) is a manifestation of systemic atherosclerosis. It is often associated with coronary and/or cerebral vascular involvement, leading to a higher risk of cardiovascular and cerebrovascular events, among which myocardial infarction, stroke, and death. Cardiovascular prevention has proven effective in reducing the progression of the disease and early diagnosis leads to more rapid initiation of medical therapy. However, revascularization of the diseased segment represents the only solution in the manifest and symptomatic forms of the disease.

Surgical treatment has historically represented the first treatment of PAD, which consists in the creation of bypasses excluding the obstructed segment. Nowadays, endovascular treatment represents in many cases the first line of intervention. Drug-coated balloons are a cornerstone solution for the treatment of peripheral lesions and are supported by multiple trials demonstrating their efficacy and safety.

New devices, such as sirolimus-eluting balloons, and also new eluting technologies will further improve the efficacy and the results of peripheral angioplasty. In the next years, we will experience the routinary use of new techniques currently under study. In this review, we will discuss the role of drug-coated balloons in the treatment of PAD.

Antiplatelet monotherapy in the chronic maintenance period for patients with high bleeding risk (HBR) and those who have undergone complex percutaneous coronary intervention (PCI) has not yet been explored.

To compare clopidogrel vs aspirin monotherapy in patients with HBR and/or PCI complexity.

This post hoc analysis of the multicenter HOST-EXAM Extended study, an open-label trial conducted across 37 sites in South Korea, enrolled patients from 2014 to 2018 with up to 5.9 years of follow-up. The analysis was conducted from February to November 2023. Patients who maintained dual antiplatelet therapy (DAPT) event-free for 6 to 18 months following PCI were included.

Patients were randomized to receive either clopidogrel or aspirin in a 1:1 ratio. Those with sufficient data to assess HBR or complex PCI were analyzed.

Coprimary end points were thrombotic composite end point (cardiovascular death, nonfatal myocardial infarction, stroke, readmission due to acute coronary syndrome, and definite/probable stent thrombosis) and any bleeding (Bleeding Academic Research Consortium type 2 to 5).

Of 3974 patients included (mean [SD] age, 63.4 [10.7] years; 2976 male [74.9%]), 866 had HBR (21.8%), and 849 underwent complex PCI (21.4%). Clopidogrel as compared with aspirin was associated with lower rates of thrombotic and bleeding events regardless of HBR and/or PCI complexity. For the thrombotic composite end point, the hazard ratio (HR) was 0.75 (95% CI, 0.53-1.04) among HBR vs 0.62 (95% CI, 0.48-0.80) among patients without HBR (P for interaction = 0.38) and 0.49 (95% CI, 0.32-0.77) among patients with complex PCI vs 0.74 (95% CI, 0.59-0.92) among patients with noncomplex PCI (P for interaction = 0.12). The reduction in bleeding by clopidogrel compared with aspirin was consistent among both patients with HBR (HR, 0.82; 95% CI, 0.56-1.21) and patients without HBR (HR, 0.58; 95% CI, 0.40-0.85; P for interaction = 0.20) and among patients undergoing complex PCI (HR, 0.79; 95% CI, 0.47-1.33) vs noncomplex PCI (HR, 0.68; 95% CI, 0.50-0.93; P for interaction = 0.62).

In this study, in patients who experienced PCI and were event-free during 6 to 18 months of DAPT, the beneficial impact of clopidogrel monotherapy over aspirin monotherapy was consistent, regardless of bleeding risk and/or PCI complexity.

ClinicalTrials.gov Identifier: NCT02044250.

Lower-extremity peripheral artery disease (PAD) affects approximately 236 million people worldwide and at least eight million people in the United States (US). Despite availability of new therapies that prevent major adverse cardiovascular events (MACE), these and major adverse limb events (MALE) remain common and occur more frequently in people with PAD, either with or without coronary artery disease (CAD), compared to people with CAD who do not have PAD. The most effective therapies to prevent cardiovascular events are not identical in people with PAD and those with CAD. Walking impairment and the risk of lower-extremity amputation are significantly greater in people with PAD compared to those without PAD. This report from the Society for Vascular Medicine (SVM) proposes and summarizes high-priority topics for scientific investigation in PAD, with the goal of improving health outcomes in people with PAD. To develop this report, a multidisciplinary team of scientists and clinicians reviewed literature, proposed high-priority topics for scientific investigation, and voted to rank the highest priority topics for scientific investigation. Priorities for clinical scientific investigation include: determine the current prevalence of PAD in the US by age, sex, race, and ethnicity; improve methods to diagnose PAD; develop new medical therapies to eliminate walking impairment; and improve implementation of established therapies to reduce rates of MACE and MALE in people with PAD. Priorities in basic science and translational science investigation include: developing animal models that closely resemble the vascular, skeletal muscle, and platelet pathology in patients with PAD and defining the genetic and epigenetic contributors to PAD and PAD-associated outcomes. Successful investigation of these research priorities will require more well-trained investigators focused on scientific investigation of PAD, greater and more efficient enrollment of diverse patients with PAD in randomized clinical trials, and increased research funding dedicated to PAD.

Management of iliac artery occlusive disease encompasses a review of peripheral arterial disease (PAD) diagnosis and treatment as a whole. There are several consensus documents that provide a comprehensive review of the topic. Differentiating optimal medical, surgical, and/or endovascular approaches to treat aortoiliac occlusive disease requires recognition of the likely etiology most responsible for the clinical symptomatology. Prompt diagnosis of acute limb ischemia versus chronic limb threatening ischemia is imperative to selecting the correct treatment pathway for individual patients. This document will attempt to summarize the data and most recent clinical trials to support clinical decision-making in the treatment of aortoiliac occlusive disease. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

The management of antiplatelet strategies among patients presenting with acute coronary syndrome (ACS) continues to evolve. Earlier studies have shown ischemic benefit with P2Y12 pretreatment in the setting of ACS; however, large-scale contemporary randomized trials supporting this strategy are lacking. This issue assumes relevance among patients with high bleeding risk or those referred for urgent/emergent coronary artery bypass surgery following coronary angiography. The evolution in the technology of percutaneous coronary intervention since the advent of newer-generation stents with lower risk of stent thrombosis is offset with their delivery in patients with high thrombotic and ischemic risk as the demographics of ACS shift towards the older age group. Coinciding with this shift, research has lagged on timing of administration of P2Y12 inhibitors resulting in discordance in the American and European guidelines, with the latter issuing a class III recommendation (ie, harm) for routine pretreatment (defined as administration of P2Y12 receptor inhibitor among patients in whom coronary anatomy is not known and an early invasive management is planned). The heterogeneity in the presentation of patients with ACS, lack of models that can predict left main or severe three-vessel disease needing urgent coronary artery bypass surgery, and shortening in the timing to angiography prompted us to review the available literature on the benefits and risks of pretreatment. With this backdrop, in this review, we synthesize the rationale for pretreatment with P2Y12 inhibitors among patients presenting with ACS. For this review, articles published in English in PubMed, MEDLINE, EMBASE, and The Cochrane Library between 1980 and 2023 were reviewed. We searched for terms, P2Y12 inhibitors (including clopidogrel, ticagrelor, prasugrel), pretreatment, percutaneous coronary intervention, and coronary artery bypass graft surgery. Abstracts and unpublished data were not included.

Elevated lipoprotein(a) [Lp(a)] levels are a causal risk factor for peripheral artery disease. However, data on their effect on delayed wound healing in patients with chronic limb-threatening ischemia (CLTI) are limited. The present study assessed the association between elevated Lp(a) levels and delayed wound healing in patients with CLTI.

This study included 280 patients who successfully received endovascular therapy for CLTI between September 2016 and August 2021. High Lp(a) levels were defined as those >30 mg/dL. The primary outcome was wound healing. During a median follow-up of 20.4 months (interquartile range 6.8-38.6 months), 146 patients achieved wound healing. The wound healing rate at 24 months was significantly lower in the high Lp(a) than low Lp(a) group (41.1% vs. 86.3%, respectively; P<0.001). The adjusted risk ratio was 0.19 (95% confidence interval 0.13-0.29, P<0.001). Lp(a) levels of 31-50 and >50 mg/dL, but not 16-30 mg/dL, were significantly associated with delayed wound healing relative to Lp(a) levels of ≤15 mg/dL.

Elevated Lp(a) levels were independently associated with delayed wound healing in patients with CLTI treated with endovascular therapy.

The optimal strategy for long-term antiplatelet maintenance for patients who underwent percutaneous coronary intervention (PCI) remains uncertain. This study aimed to compare the efficacy and safety of clopidogrel versus aspirin monotherapy in patients who completed a standard duration of dual antiplatelet therapy (DAPT) following PCI with drug-eluting stents.

In this multicentre, randomised, open-label trial, patients aged 19 years or older at high risk of recurrent ischaemic events (previous myocardial infarction at any time before enrolment, medication-treated diabetes, or complex coronary lesions) who completed a standard duration of DAPT after PCI were randomly assigned (1:1) to receive clopidogrel (75 mg once a day) or aspirin (100 mg once a day) oral monotherapy at 26 sites in South Korea. The primary endpoint was the cumulative incidence of a composite of death from any cause, myocardial infarction, or stroke, assessed in the intention-to-treat population. Adverse events were captured as part of the secondary endpoints. This trial is registered with ClinicalTrials.gov (NCT04418479). It is closed to accrual and extended follow-up is ongoing.

Between Aug 10, 2020, and July 31, 2023, 5542 patients were assessed for eligibility and 5506 were randomly assigned (2752 to clopidogrel monotherapy and 2754 to aspirin monotherapy). The median time between PCI and randomisation was 17·5 months (IQR 12·6-36·1 months). During a median follow-up period of 2·3 years (IQR 1·6-3·0), the primary endpoint occurred in 92 patients in the clopidogrel group and 128 patients in the aspirin group (Kaplan-Meier estimated 3-year incidence 4·4% [95% CI 3·4-5·4] vs 6·6% [5·4-7·8]; hazard ratio 0·71 [95% CI 0·54-0·93]; p=0·013). Death from any cause occurred in 50 patients in the clopidogrel group and 70 in the aspirin group (2·4% [1·6-3·1] vs 4·0% [2·9-5·0] at 3 years; 0·71 [0·49-1·02]); myocardial infarction in 23 patients in the clopidogrel group and 42 in the aspirin group (1·0% [0·6-1·4] vs 2·2% [1·4-2·9] at 3 years; 0·54 [0·33-0·90]); and stroke in 23 in the clopidogrel group and 29 in the aspirin group (1·3% [0·7-2·0] vs 1·3% [0·8-1·7] at 3 years; 0·79 [0·46-1·36]). There was no difference in the risk of bleeding between the clopidogrel and aspirin groups (3·0% [2·0-3·9] vs 3·0% [2·2-3·9] at 3 years; 0·97 [0·67-1·42]). Clopidogrel was not associated with a higher incidence of any adverse event compared with aspirin.

Among patients who were at high risk of recurrent ischaemic events and who completed the standard duration of DAPT following PCI, clopidogrel monotherapy, compared with aspirin monotherapy, significantly reduced the cumulative incidence of a composite of death from any cause, myocardial infarction, and stroke, without an apparent increase in the risk of bleeding.

Dong-A ST.

Peripheral artery disease (PAD) is a highly prevalent subset of cardiovascular disease associated with significant limb-related and concomitant atherosclerotic complications, resulting in high morbidity and mortality. Consequently, appropriate identification and timely initiation of guideline-directed medical therapy is crucial. Despite its widespread prevalence, PAD remains underdiagnosed and undertreated, posing a substantial public health challenge. This review delves into the evidence-based nonpharmacological and pharmacologic treatment strategies for PAD, underscoring the necessity of a multidisciplinary approach.

Peripheral arterial disease (PAD) is characterized by atherosclerotic arterial occlusive disease of the lower extremities and is associated with an increased risk of major adverse cardiovascular events (MACE) in addition to disabling clinical sequelae, including intermittent claudication and chronic limb-threatening ischemia (CLTI). Given the growing burden of disease, knowledge of modern practices to prevent MACE and major adverse limb events (MALE) is essential. This review article examines evidence for medical management of PAD and its associated risk factors, as well as wound prevention and care.

A thorough review of the literature was performed, with attention to evidence for the management of modifiable atherosclerotic risk factors, claudication symptoms, wound prevention, and wound care.

Contemporary management of PAD requires a multi-faceted approach to care, with medical optimization of smoking, hypertension, hyperlipidemia, and diabetes mellitus. The use of supervised exercise therapy for intermittent claudication is highlighted. The anatomic disease patterns of smoking and diabetes mellitus are discussed further, and best practices for diabetic foot ulcer prevention, including offloading footwear, are described. Quality wound care is essential in this patient population and involves strategic use of debridement, wound-healing adjuncts, and skin substitutes, when appropriate.

The objective of medical management of PAD is to reduce the risk of MACE and MALE. Atherosclerotic risk factor optimization, appropriate wound care, and management of diabetic foot ulcers, foot infections, gangrene, and chronic, non-healing wounds are critical components of PAD care. Interdisciplinary care is essential to coordinate care, leverage expertise, and improve outcomes.

Chronic limb-threatening ischemia (CLTI) is the end-stage presentation of peripheral artery disease and requires comprehensive care. Despite advancements in treatments, providing timely and equitable care remains challenging. Ongoing research and interdisciplinary collaboration are vital for improving outcomes. Implementing strategies that combine appropriate diagnostics, advanced and innovative revascularization techniques, guideline-directed medical therapies, and efforts to tackle socioeconomic disparities can better address patient needs and enhance quality and quantity of life. This multifaceted approach offers promise for improved long-term outcomes in CLTI patients.

The lack of diverse and inclusive clinical research populations fuels health inequalities in the UK, and there is an urgent need to reverse this. This communication provides a practical framework for positive action to integrate equity, diversity and inclusion (EDI) processes into clinical research design, protocols and implementation and to establish accountable clinical research systems that are trustworthy to the public and accessible to diverse communities.This framework is a consensus-based guide developed by the Equality, Diversity and Inclusion working group of the National Institute for Health and Care Research's (NIHR's) Clinical Research Network in North West London. This work involved analysing challenges to integrating EDI within the clinical research process, such as clinical trial protocols as directed by industry sponsors and National Health Service investigator teams. It aligns with the UK government's clinical research strategy and NIHR's INCLUDE project.It advises an interconnected approach to embedding EDI throughout the clinical research lifecycle. By following this framework, we aspire to guide clinical research towards a more equitable, inclusive and representative model that better serves the needs of all populations.

ObjectiveEndovascular treatment (EVT) for an aorto-iliac occlusive lesion is performed worldwide as first-line treatment. However, the choice of single antiplatelet therapy (SAPT) or double antiplatelet therapy (DAPT) after aorto-iliac revascularization is controversial. The purpose of the study was to assess clinical outcomes in patients with SAPT or DAPT after iliac EVT, using propensity score matching.MethodPatients who underwent EVT for a de-novo iliac occlusive lesion at a single center from 2017 to 2023 were analyzed retrospectively. Comparisons were made between SAPT and DAPT cases after propensity score matching. The primary endpoints of the study were freedom from restenosis and freedom from target lesion revascularization (TLR).ResultsA total of 150 patients underwent iliac EVT and received SAPT (n = 93) or DAPT (n = 57). The DAPT group had a significantly higher rate of coronary artery disease (P = .010). After matching, the differences in baseline and procedural details were diminished. The technical success rate of EVT, access site complications, and manual compression time did not differ between the groups. The median follow-up period was 33 (20-47) months. During follow-up, restenosis occurred in 11 cases (7%) and 10 cases (7%) underwent TLR. After matching, the 5-year freedom from restenosis did not differ significantly in the SAPT and DAPT groups (92% vs 90%, P = .80). Freedom from TLR also did not differ between the groups (P = .80). There was a tendency for a lower incident rate of major bleeding in the SAPT group (7% vs 18% at 5 years, P = .10).ConclusionsRetrospective analysis using propensity score matching showed that SAPT after iliac EVT resulted in similar freedom from restenosis and TLR compared with DAPT.

This systematic review and meta-analysis compared the efficacy and safety of P2Y12 inhibitors versus aspirin monotherapy for secondary prevention in patients with coronary heart disease (CAD), providing evidence for clinical decision-making.

Following the PRISMA and AMSTAR2 guidelines, a comprehensive literature search was conducted in PubMed, EMBASE, Web of Science, and the Cochrane Library to identify randomized controlled trials (RCTs) comparing P2Y12 inhibitors and aspirin monotherapy in CAD patients. The inclusion criteria focused on RCTs comparing P2Y12 inhibitors (clopidogrel, ticagrelor, and prasugrel) with aspirin. Studies that were non-randomized, did not focus on monotherapies with these agents, involved patients under 18 years old, or included non-CAD patients were excluded. The primary outcomes included myocardial infarction (MI) and stroke, while secondary outcomes comprised gastrointestinal complications, major bleeding, and mortality. The Cochrane Risk of Bias tool was used to assess the risk of bias. A random-effects model was applied to calculate risk ratios (RR) with 95% confidence intervals (CI), and sensitivity analyses were conducted to evaluate the robustness of the findings.

A total of 31,956 patients were included in the meta-analysis. P2Y12 inhibitors significantly reduced the risk of myocardial infarction (RR: 0.77, 95% CI: 0.67 to 0.89, I² = 0%, P < 0.001) and hemorrhagic stroke risk (RR: 0.53, 95% CI: 0.30 to 0.92, I² = 20.2%, P = 0.025). No statistically significant difference was observed in major bleeding (RR: 0.96, 95% CI: 0.71 to 1.30, I² = 63.8%, P = 0.814) or all-cause mortality (RR: 0.99, 95% CI: 0.85 to 1.15, I² = 30.3%, P = 0.877). Heterogeneity was assessed, and sensitivity analysis confirmed the robustness of the primary findings.

Compared with aspirin, P2Y12 inhibitors reduce risk of myocardial infarction and hemorrhagic stroke in the secondary prevention of CAD. However, there is no significant differences in major bleeding or all-cause mortality. Further research, including subgroup analyses and studies in diverse populations, is needed to validate these findings and explore genetic factors that may influence treatment outcomes.

Background: Dual-pathway inhibition (DPI) with aspirin and rivaroxaban exhibited a net clinical benefit for patients with cardiovascular disease in the randomized COMPASS trial. The non-observational, international XATOA registry showed that the COMPASS results can be reproduced in clinical practice in patients with coronary artery disease (CAD) and peripheral artery disease (PAD). Here we report patient characteristics and clinical outcomes for the subgroup of German PAD patients of the XATOA registry and compare them to COMPASS PAD patients. Patients and methods: XATOA was an international prospective registry of patients receiving DPI with a mean follow-up period of 15 months. The subgroup of German patients with PAD in XATOA comprised 1,819 patients, of which 925 patients (50.9%) had only PAD and 894 patients (49.1%) had both CAD and PAD. Patient characteristics such as prior medical history and prior medications as well as clinical outcomes such as incidences of major adverse limb events (MALE), major adverse cardiovascular events (MACE) and major bleeding events were assessed. Results: DPI was well-tolerated in clinical practice. Patient characteristics and clinical outcomes especially for patients with only PAD differed from characteristics and outcomes of the overall German XATOA population as well as the PAD subgroup of COMPASS. Patients with only PAD were markedly less supplied with lipid-lowering agents and betablockers. Incidences of MALE were high in German PAD patients of XATOA (9.0%) and markedly higher than in the PAD subgroup of COMPASS (1.2%). Incidences of MACE and major bleeding events were lower in German PAD patients of XATOA (MACE: 2.9%, major bleeding: 1.4%) than in PAD patients of COMPASS (MACE: 5.1%, major bleeding: 3.1%). Conclusions: DPI with rivaroxaban and aspirin is well-tolerated by PAD patients in German clinical practice. PAD patients in Germany exhibit different characteristics and show a different clinical outcome profile than PAD patients in COMPASS.

Dual antiplatelet therapy (DAPT), consisting of aspirin and a P2Y12inhibitor, has been the principal antiplatelet therapy after drug-eluting stent (DES) implantation in patients with acute coronary syndrome (ACS) and chronic coronary disease. Particularly in patients with ACS, which presents a higher ischemic risk than chronic coronary artery disease, DAPT for up to 12 months is the recommended standard treatment. However, to decrease bleeding events related to the potency of P2Y12inhibitors and a prolonged duration of DAPT, recent studies have suggested P2Y12inhibitor monotherapy after short-term DAPT (1-3 months), which decreased the bleeding risk without an increased ischemic risk. In this article, we discuss the evidence related to the efficacy of a P2Y12inhibitor as single-antiplatelet therapy after short-term DAPT compared with standard DAPT, with a focus on patients with ACS treated with DES.

Acute coronary syndrome (ACS) remains one of the leading causes of death globally. Accurate and reliable mortality risk prediction of ACS patients is essential for developing targeted treatment strategies and improve prognostication. Traditional models for risk stratification such as the GRACE and TIMI risk scores offer moderate discriminative value, and do not incorporate contemporary predictors of ACS prognosis. Machine learning (ML) models have emerged as an alternate method that may offer improved risk assessment. This review compares ML models with traditional risk scores for predicting all-cause mortality in patients with ACS.

PubMed, Embase, Web of Science, Cochrane, CINAHL, Scopus, and IEEE XPlore databases were searched through October 30, 2024, as well as Google Scholar and manual screening of reference lists from included studies and the grey literature for studies comparing ML models with traditional statistical methods for event prediction of ACS patients. The primary outcome was comparative discrimination measured by C-statistics with 95% confidence intervals (CIs) in estimating risk of all-cause mortality.

Twelve studies were included (250,510 patients). The summary C-statistic of best-performing ML models across all end points was 0.88 (95% CI 0.86-0.91), compared with 0.82 (95% CI 0.80-0.85) for traditional methods. The difference in C-statistic between ML models and traditional methods was 0.06 (P < 0.0007). Five studies undertook external validation. The PROBAST tool demonstrated high risk of bias for all studies. Common sources of bias included reporting bias and selection bias. Best-performing ML models demonstrated superior discrimination of all-cause mortality for ACS patients compared with traditional risk scores.

Despite outperforming well established prognostic tools such as the GRACE and TIMI scores, current clinical applications of ML approaches remain uncertain, particularly in view of the need for greater model validation.

The present guidelines recommend dual antiplatelet therapy (DAPT) for 6 to 12 months after percutaneous coronary intervention (PCI), with recent trials assessing the safety and efficacy of shortening DAPT duration to ≤3 months. A systematic search of PubMed, Scopus, and Cochrane Central databases identified studies comparing short DAPT, followed by P2Y12i monotherapy (78% ticagrelor) versus standard 12-month DAPT in patients who underwent PCI with a drug-eluting stent. A total of 9 randomized controlled trials, including 42,770 patients (short DAPT n = 21,370, 49.96%), of whom 28,307 (66.18%) presented with acute coronary syndrome (ACS). Short DAPT significantly reduced net adverse clinical events (NACEs) (risk ratio [RR] 0.78, 95% confidence interval [CI] 0.67 to 0.91, p = 0.001, I2 = 62%), major bleeding (RR 0.54, 95% CI 0.39 to 0.73, p <0.001, I2 = 63%), and any bleeding (RR 0.55, 95% CI 0.43 to 0.72, p <0.001, I2 = 77%) at 12 months compared with 1-year DAPT. No significant differences were observed in major adverse cardiovascular/cerebrovascular events, myocardial infarction, stroke, stent thrombosis, mortality, or revascularization. Ticagrelor monotherapy after short DAPT further reduced major adverse cardiovascular/cerebrovascular events (RR 0.85, 95% CI 0.73 to 0.99, p = 0.040, I² = 22%), NACE (RR 0.74, 95% CI 0.61 to 0.89, p = 0.001, I² = 68%), and major bleeding (RR 0.56, 95% CI 0.40 to 0.78, p <0.001, I² = 71%) compared with 1-year DAPT; however, the test for subgroup interaction (Pinteraction >0.05) for clopidogrel subgroup was not significant. P2Y12i monotherapy reduced the risk of NACEs (RR 0.77, 95%CI 0.66 to 0.90, p = 0.001, I2 = 52%, Pinteraction = 0.58) and major bleeding (RR 0.44, 95%CI 0.35 to 0.55, p <0.001, I2 = 0%, Pinteraction <0.01) in the ACS cohort but not in the chronic coronary syndrome cohort. In conclusion, short DAPT for ≤3 months followed by P2Y12i monotherapy (particularly, ticagrelor) was associated with decreased NACEs and bleeding without differences in other outcomes and should be considered a favorable option in patients with either ACS or chronic coronary syndrome after PCI with a drug-eluting stent.

Many researchers nowadays choose multi-omics techniques for myocardial infarction studies. However, there's yet to be a review article integrating myocardial infarction multi-omics. Hence, this study adopts the popular bibliometrics. Based on its principles, we use software like R Studio, Vosviewer, Citespace, and SciMAT to analyze literature data of myocardial infarction omics research (1991-2022) from Web of Science. By extracting key information and calculating weights, we conduct analyses from 4 aspects: Collaboration Network Analysis, Co-word Analysis, Citing and Cited Journal Analysis, and Co-citation and Clustering Analysis, aiming to understand the field's cooperation, research topic evolution, and knowledge flow. The results show that myocardial infarction omics research is still in its early stage with limited international cooperation. In terms of knowledge flow, there's no significant difference within the discipline, but non-biomedical disciplines have joined, indicating an interdisciplinary integration trend. In the overall research field, genomics remains the main topic with many breakthroughs identifying susceptibility sites. Meanwhile, other omics fields like lipidomics and proteomics are also progressing, clarifying the pathogenesis. The cooperation details in this article enable researchers to connect with others, facilitating their research. The evolution trend of subject terms helps them set goals and directions, quickly grasp the development context, and read relevant literature. Journal analysis offers submission suggestions, and the analysis of research base and frontier provides references for the research's future development.

The hemostatic function of platelets is complementary to blood coagulation. However, traditional platelet function tests have primarily focused on measuring platelet aggregation, reducing their clinical effectiveness for antiplatelet drug monitoring. To address this limitation, we propose a new test principle that evaluates platelet function and the effects of antiplatelet drugs through blood coagulation reactions. This principle was validated in model experimental systems using blood samples from healthy volunteers (n = 11), where antiplatelet drugs such as aspirin, prostaglandin E1, or ticagrelor were added to the blood samples. Ticagrelor was tested at four concentration levels, covering the expected therapeutic range. We found that the complementary function of platelets can be assessed by monitoring the 1 MHz dielectric permittivity during the blood coagulation process, particularly the peak value. When reagents such as agonists (arachidonic acid, collagen, or adenosine diphosphate ADP) and calcium were mixed into the citrated blood with turbulence by pipetting, platelets became activated and aggregated before thrombin generation, resulting in a "consumed" state of platelets. Consequently, the contribution to the permittivity peak was minimal. By contrast, when blood spiked with antiplatelet drugs was tested, agonist-induced platelet aggregation was inhibited during the initial stage of the measurement. However, after thrombin generation, platelets were activated through the thrombin receptor. These activated platelets interacted with fibrin, thereby affecting the permittivity peak. The results of this validation process with Student's t-tests confirm the fundamental operating principle of the proposed platelet function assay, thereby contributing to antiplatelet therapy monitoring.

Advances in pharmacotherapy for coronary thrombosis treatment and prevention have transformed the clinical outcomes of patients with coronary artery disease but increased the complexity of therapeutic decision-making. Improvements in percutaneous coronary intervention techniques and stent design have reduced the incidence of thrombotic complications, which consequently has increased the challenge of adequately powering clinical trials of novel antithrombotic strategies for efficacy outcomes. Knowledge of the pathophysiology of coronary thrombosis and the characteristics of antithrombotic drugs can help with therapeutic decisions.

This review covers the pathophysiology of coronary thrombosis and the mechanisms of action of drugs developed for its treatment, provides an overview of the key issues in decision-making, and highlights key areas for further work in order to guide clinicians on how to individualize risk management and address gaps in the evidence base.

Individualization of antithrombotic therapy regimens has become a vital part of optimizing risk management in people with coronary thrombosis. A critical appraisal of the strengths and limitations of available drugs and the evidence supporting the use of different antithrombotic combinations is intended to provide direction to clinicians and point the way toward further improvements in pharmacotherapy for coronary thrombosis treatment and prevention.

Antiplatelet therapy is used to prevent thrombosis in patients with peripheral artery disease (PAD) following revascularization. However, the current standard of care for these patients remains at the physician's discretion, varying from mono-antiplatelet therapy (MAPT) to dual-antiplatelet therapy (DAPT). Viscoelastic assays such as Thromboelastography with Platelet Mapping (TEG-PM) provide insight into individual coagulation profiles and measure real-time platelet function. This prospective, observational study looks at the differences in platelet function for patients on MAPT versus DAPT using TEG-PM.

Patients with PAD undergoing revascularization were prospectively evaluated between December 2020 and June 2023. TEG-PM analysis compared platelet function for patients prescribed MAPT (aspirin or clopidogrel) at the initial encounter and DAPT (aspirin and clopidogrel) at the next visit. Platelet function measured in percent inhibition was evaluated at these visits, and within-group t-tests were performed.

Of the 195 patients enrolled, 486 samples were analyzed by TEG-PM. Sixty-four patients met the study criteria. At the initial visit, 52 patients had been prescribed aspirin, and 12 patients had been prescribed clopidogrel. For patients initially prescribed aspirin MAPT, an increase of 96.8%in the mean ADP platelet inhibition was exhibited when transitioning to DAPT [22.0% vs. 43.3%, p < .01], as well as an increase of 34.6%in the mean AA platelet inhibition when transitioning to DAPT [60.9% vs. 82.0%, p < .01]. For patients prescribed initial clopidogrel MAPT, an increase of 100% in AA platelet inhibition was exhibited on DAPT compared to the MAPT state [42.3% vs. 84.6%, p < .01].

Patients on DAPT showed a significant increase in platelet inhibition when compared to initial aspirin MAPT. A significant difference in AA %platelet inhibition was shown for patients on DAPT when compared to initial clopidogrel MAPT. The results show that patients may benefit from DAPT post-revascularization. Personalizing antiplatelet therapy with objective viscoelastic testing to confirm adequate treatment may be the next step in optimizing patient outcomes to reduce thrombosis in PAD patients.

The 2024 European Society of Cardiology (ESC) guidelines on chronic coronary syndrome comprehensively summarize the symptoms, diagnostics and treatment of coronary artery disease, excluding acute coronary syndromes. The processing always begins with an estimation of the clinical probability, which should include not only the symptom profile but also the number of cardiovascular risk factors and is further modified by any conspicuous findings in electrocardiography (ECG), exercise testing, or echocardiography. For further diagnostics, coronary angiography via computed tomography is the first-line approach if the probability lies between 5% and 50%. For probabilities of 50-85% procedures for imaging-based ischemia detection are indicated, while for even higher probabilities immediate invasive diagnostics are given priority. The treatment includes intensive risk modification, medicinal anti-anginal treatment and finally revascularization by coronary intervention or bypass surgery. In the absence of high-risk constellations a medication-based approach should be initially preferred, with revascularization indicated if symptoms persist. The new guidelines also extensively address angina and ischemia without obstructive coronary lesions. In this context, intensive risk modification and initial medication treatment are again recommended.

To evaluate the efficacy and safety of clopidogrel-rivaroxaban combination compared to aspirin-rivaroxaban combination in patients with symptomatic peripheral artery disease (PAD).

Consecutive patients with symptomatic PAD patients were analyzed from January, 2018 to June, 2022 at Nanjing Drum Tower Hospital. Patients were divided into two groups based on the antithrombotic therapy. The primary efficacy outcome was a composite of major adverse cardiovascular events (MACE) and major adverse limb events (MALE), and the primary safety outcome was major bleeding. Patients were followed until the first occurrence of any outcomes or the study end date (30 June 2024).

A total of 695 patients were enrolled into this study. The clopidogrel-rivaroxaban combination significantly reduced the risk of composite outcome (HR: 0.59, 95%CI: 0.41-0.83) without increasing the risk of major bleeding (HR: 0.68, 95%CI: 0.27-1.69). When analyzed separately, clopidogrel-rivaroxaban combination was associated with a reduced risk of MALE (HR: 0.61, 95%CI: 0.41-0.91), although no significant differences were observed in terms of MACE (HR: 0.64, 95%CI: 0.34-1.20) or all bleeding events (HR: 1.00, 95%CI: 0.52-1.93). In the subgroup analysis, there were no significant interactions between the treatment groups and the subgroups of age, diabetes, lesion sites, Rutherford classifications and renal function for composite outcome, MACE and MALE.

The clopidogrel-rivaroxaban combination in PAD patients may offer enhanced cardiovascular protection without increasing the risk of bleeding complications. These findings suggested that clopidogrel could be a superior alternative to aspirin in dual antithrombotic therapy for PAD management.

Mislabeled drug allergy can restrict future prescriptions and medication use, but its prevalence and impact among patients with stroke remain unknown. This study investigated the prevalence of the most commonly labeled drug allergies, their accuracy, and their impact among patients with stroke.

In this combined longitudinal and cross-sectional study, we compared the prevalence of allergy labels among the general population and patients with ischemic stroke between 2008 and 2014 from electronic health care records in Hong Kong. Outcomes between patients with stroke with or without the most prevalent labels (ie, NSAID) were compared. Rate of mislabeled NSAID allergy was confirmed by provocation testing.

Compared with the general population (n=702 966), patients with stroke had more labels (n=235) to cardiovascular and hematopoietic system (prevalence, 19.5% versus 9.2%; odds ratio [OR], 2.4 [95% CI, 1.74-3.32]; P<0.001) and radiographic and diagnostic agents (prevalence, 4.2% versus 0.9%; OR, 4.82 [95% CI, 2.56-9.08]; P<0.001). The most common labels were to NSAID (prevalence, 1.8%). Patients with NSAID allergy labels were significantly less likely to be prescribed aspirin after acute stroke (OR, 0.24 [95% CI, 0.09-0.60]; P=0.003) and on follow-up (OR, 0.22 [95% CI, 0.08-0.56]; P=0.002). The median duration of follow-up was 6.7 years (6499±2.49 patient-years). Patients with stroke with NSAID allergy labels also experienced significantly higher mortality (OR, 7.44 [95% CI, 2.44-23.18]; P<0.001), peripheral vascular disease (OR, 9.35 [95% CI, 1.95-44.86]; P=0.005), and major adverse cardiovascular events (OR, 6.09 [95% CI, 2.00-18.58]; P=0.001) in the poststroke period. Patients with NSAID allergy labels (who remained alive and could consent) were referred for allergist assessment and offered drug provocation testing. The majority (80%; 4/5) had negative provocation tests and were delabeled.

NSAID allergy labels were significantly more prevalent among patients with stroke, associated with excessive mortality, peripheral vascular disease, and major adverse cardiovascular events. Given the high rate of mislabeled allergies, multidisciplinary neuro-allergy interventions could have the potential to improve patient outcomes.

Randomized clinical trials are important in both clinical and academic stroke communities with increasing numbers of new design concepts emerging. One of the "less traditional" designs that have gained increasing interest in the last decade is non-inferiority trials. Whilst the concept might appear straightforward, the design and interpretation of non-inferiority trials can be challenging. In this review, we will use exemplars from clinical trials in the stroke field to provide an overview of the advantages and limitations of non-inferiority trials and how they should be interpreted in stroke research.

Optimal medical therapy (OMT) is a modifiable factor that decreases mortality and cardiovascular events in patients with severe peripheral arterial disease. We hypothesized that preintervention OMT would be associated with improved 1-year reintervention and major adverse limb event (MALE) rates after elective endovascular revascularization for intermittent claudication (IC).

Using the Vascular Quality Initiative (2010-2020), we identified patients with IC undergoing elective endovascular, hybrid, and open surgical interventions. Preoperative antiplatelet, statin, and nonsmoking status defined OMT components and created three groups: complete (all components), partial (1-2 components), and no OMT. The primary outcome was 1-year reintervention. Secondary outcomes included MALE and factors associated with OMT usage. Multivariable logistic regression generated adjusted odds ratios (aOR).

There were 39,088 patients (14,907 [38.1%] complete, 22,054 [56.4%)] partial, 2127 [5.4%] no OMT) who met our criteria. Patients with any OMT were more frequently older with more cardiovascular diseases and diabetes (P < .0001). Patients without OMT were more likely to be Black or with Medicare or Medicaid (P < .05). Observed 1-year reintervention (5.3% complete OMT, 6.1% partial OMT, 8.3% no OMT; P < .001) and MALE (5.6% complete OMT, 6.3% partial OMT, 8.8% no OMT; P < .001) were decreased by partial or complete OMT compared with no OMT. Complete OMT significantly decreased the adjusted odds of reintervention and MALE by 28% (aOR, 0.72, 95% confidence interval [95% CI], 0.59-0.88) and 30% (aOR, 0.70; 95% CI, 0.58-0.85), respectively, compared with no OMT. Partial OMT decrease the adjusted odds of reintervention and MALE by 24% (aOR, 0.76; 95% CI, 0.63-0.92) and 26% (aOR, 0.74; 95% CI, 0.62-0.89), respectively.

Preintervention OMT is an underused, modifiable risk factor associated with improved 1-year reintervention and MALE. Vascular surgeons are uniquely positioned to initiate and maintain OMT in patients with IC before revascularization to optimize patient outcomes.

Comorbid diabetes mellitus (DM) in patients with ischemic heart disease (IHD) is a serious factor that significantly impairs the life prognosis and increases the risk of cardiovascular complications (CVC) as well as the likelihood of death. The residual risk of developing CVC in such patients is largely determined by the high thrombotic status, that is associated with hypercoagulation characteristic of DM. Hypercoagulation causes activation of both platelet and coagulation pathways, which leads to an increased susceptibility to thrombosis. In this context, the combined administration of the anticoagulant rivaroxaban (Xarelto®) 2.5 mg and acetylsalicylic acid (ASA) can significantly reduce this risk by affecting both mechanisms of thrombus formation and thereby improving the prognosis. Rivaroxaban 2.5 mg in combination with ASA is the only available strategy to intensify the antithrombotic therapy in patients with stable IHD and DM with no history of ischemic events. Importantly, such therapy should be initiated as early as possible to prevent clinically significant CVCs and improve patients' quality of life.

Objectives: Evidence for antithrombotic therapy after endovascular therapy (EVT) is limited. Methods: This retrospective, multicenter, observational study enrolled 732 consecutive patients with lower extremity artery disease who underwent EVT between January 2018 and December 2019. Overall, 570 patients who received single antiplatelet therapy (SAPT) and dual antiplatelet therapy (DAPT) were selected and divided into the SAPT (n = 189) and DAPT (n = 381) groups. The primary outcome was bleeding events at 24 months. The secondary outcomes were bleeding events at 30 days and 24 months after 30 days, ischemic events, and all-cause death at 24 months. Bleeding and ischemic events at 24 months were investigated in subgroups. Results: A propensity score matching yielded 164 patients in both groups. There were no significant differences in bleeding events between the SAPT and DAPT groups (14.2% and 11.3% at 24 months, p = 0.775; 2.5% and 6.1% at 30 days, p = 0.106; 11.7% and 6.7% at 24 months after 30 days, p = 0.162). Additionally, there was no significant difference in ischemic events at 24 months between the two groups (32.7% and 30.6%, p = 0.625). Bleeding and ischemic events at 24 months were similar between subgroups. Conclusions: No significant differences in bleeding or ischemic events between SAPT and DAPT were observed.

Patients undergoing revascularization of the lower extremities have unacceptably high rates of major adverse cardiac and limb events despite the routine use of antiplatelet therapy. Optimization of antithrombotic therapy provides an opportunity to reduce this risk. Recent large, randomized trials have demonstrated substantial benefit from the combination of low-dose rivaroxaban and aspirin compared with aspirin alone. Despite this new evidence, uptake remains limited.

This review will outline the drug profile of rivaroxaban, summarize the key efficacy and safety data for the combination of low-dose rivaroxaban and aspirin following lower extremity revascularization, and examine barriers to therapy uptake.

Combination of low-dose rivaroxaban and aspirin is the only antithrombotic regimen that has been shown to reduce both cardiac and limb events following peripheral revascularization while maintaining an acceptable bleeding profile. Single and dual antiplatelet therapy have limited randomized evidence for this indication, but are commonly used. An important contributor is the failure of major societal guidelines to incorporate this new evidence. Moving forward, there is an urgent need to update these guidelines. Further evaluation of the efficacy and safety of dual antiplatelet therapy will help to inform optimal antithrombotic therapy after lower extremity revascularization.

To highlight current evidence pertaining to the measurement methods and prevalence of high on-treatment platelet reactivity (HTPR) in patients with PAD, as well as to evaluate the relationship between HTPR and recurrent adverse cardiovascular and limb events in PAD patients.

A systematic review of English-language literature on HTPR in patients with PAD. An electronic literature search of PubMed and Medline was performed in May 2021.

A total of 29 studies with a total number of 11,201 patients with PAD were identified. HTPR during clopidogrel treatment ranges from 9.8 to 77%, and during aspirin treatment ranges from 4.1 to 50% of PAD patients. HTPR was associated with adverse clinical outcomes. The need for limb revascularisation was higher in patients with HTPR during clopidogrel use. Similarly, HTPR during aspirin use in the PAD population was predictive of adverse cardiovascular events (HR 3.73; 95% CI, 1.43-9.81; p = .007). A wide range of techniques were applied to measure platelet resistance, without consensus on cut-off values. Furthermore, differing patient populations, a variety of antiplatelet regimens, and differing clinical endpoints highlight the high degree of heterogeneity in the studies included in this review.

No consensus on technique or cut-off values for HTPR testing has been reached. Patients with HTPR are potentially at a greater risk of adverse limb-related and cardiovascular events than patients sensitive to antiplatelet therapy illustrating the need for clinical implementation of HTPR testing. Future research must aim for consistent methodology. Adaptation of antiplatelet therapy based on HTPR results requires further exploration.

The optimal duration of dual antiplatelet therapy (DAPT) in patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI) remains under debate.

To analyze the efficacy and safety of DAPT strategies in patients with ACS using a bayesian network meta-analysis.

MEDLINE, Embase, Cochrane, and LILACS databases were searched from inception to April 8, 2024.

Randomized clinical trials (RCTs) comparing DAPT duration strategies in patients with ACS undergoing PCI were selected. Short-term strategies (1 month of DAPT followed by P2Y12 inhibitors, 3 months of DAPT followed by P2Y12 inhibitors, 3 months of DAPT followed by aspirin, and 6 months of DAPT followed by aspirin) were compared with conventional 12 months of DAPT.

This systematic review and network meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The risk ratio (RR) with a 95% credible interval (CrI) was calculated within a bayesian random-effects network meta-analysis. Treatments were ranked using surface under the cumulative ranking (SUCRA).

The primary efficacy end point was major adverse cardiac and cerebrovascular events (MACCE); the primary safety end point was major bleeding.

A total of 15 RCTs randomizing 35 326 patients (mean [SD] age, 63.1 [11.1] years; 26 954 male [76.3%]; 11 339 STEMI [32.1%]) with ACS were included. A total of 24 797 patients (70.2%) received potent P2Y12 inhibitors (ticagrelor or prasugrel). Compared with 12 months of DAPT, 1 month of DAPT followed by P2Y12 inhibitors reduced major bleeding (RR, 0.47; 95% CrI, 0.26-0.74) with no difference in MACCE (RR, 1.00; 95% CrI, 0.70-1.41). No significant differences were observed in MACCE incidence between strategies, although CrIs were wide. SUCRA ranked 1 month of DAPT followed by P2Y12 inhibitors as the best for reducing major bleeding and 3 months of DAPT followed by P2Y12 inhibitors as optimal for reducing MACCE (RR, 0.85; 95% CrI, 0.56-1.21).

Results of this systematic review and network meta-analysis reveal that, in patients with ACS undergoing PCI with DES, 1 month of DAPT followed by potent P2Y12 inhibitor monotherapy was associated with a reduction in major bleeding without increasing MACCE when compared with 12 months of DAPT. However, an increased risk of MACCE cannot be excluded, and 3 months of DAPT followed by potent P2Y12 inhibitor monotherapy was ranked as the best option to reduce MACCE. Because most patients receiving P2Y12 inhibitor monotherapy were taking ticagrelor, the safety of stopping aspirin in those taking clopidogrel remains unclear.