ReviewsDe-escalating dual antiplatelet therapy in patients with acute coronary syndromes: the right strategy to harmonize time-dependent ischemic and bleeding risk in elderly patients?Crimi, Gabrielea,b; De Rosa, Robertac; Mandurino-Mirizzi, Alessandroa; Morici, Nucciad; Alberti, Luca Paoloe; Savonitto, Stefanoe; De Servi, StefanofAuthor Information aSC. Cardiologia, Fondazione Policlinico San Matteo, Pavia bCardiologia Interventistica, Dipartimento CardioToracoVascolare, IRCCS Ospedale Policlinico San Martino, Genoa, Italy cDepartment of Medicine, Surgery and Dentistry, Schola Medica Salernitana, University of Salerno dIntensive Cardiac Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan eCardiovascular Department, Ospedale Manzoni, Lecco fIRCCS Multimedica, Sesto San Giovanni, Milan, Italy Correspondence to Stefano De Servi, IRCCS Multimedica, Sesto San Giovanni, Milan, Italy E-mail: [email protected] Received 2 July, 2019 Revised 17 November, 2019 Accepted 7 December, 2019 Journal of Cardiovascular Medicine: April 2020 - Volume 21 - Issue 4 - p 281-285 doi: 10.2459/JCM.0000000000000929 Buy Metrics Abstract The European Society of Cardiology guidelines for myocardial revascularization state that de-escalation of P2Y12 inhibitor treatment guided by platelet function testing may be considered for acute coronary syndrome (ACS) patients deemed unsuitable for 12-month potent platelet inhibition. De-escalation strategy aim is to harmonize the time-dependency of thrombotic risk, which is high in the first month after ACS, then decreases exponentially, with bleeding risk, which tends to remain more stable after the procedure-related peak. Harmonizing time-dependency of clinical events may be particularly relevant in those at high risk, such as the elderly patients with ACS in whom an individualized antiplatelet therapy may be more appropriate than a ‘one-size-fits all’ approach. In this review, we outline the current medical evidence on the topic of dual antiplatelet therapy de-escalation. In addition, we include insights from the Elderly ACS 2 study and recently published post-hoc analyses conducted by the authors’ consortium, which further expands current knowledge. © 2020 Italian Federation of Cardiology - I.F.C. All rights reserved.