Guidelines for Antithrombotic Therapy
Cardiovascular research in 2025 has further refined antithrombotic management in acute coronary syndromes (ACS), atrial fibrillation (AF), and prosthetic valve disease, with a strong emphasis on individualized risk assessment and bleeding reduction.
In ACS, the TARGET-FIRST trial showed that stopping aspirin after one month of dual antiplatelet therapy (DAPT) and continuing potent P2Y12 inhibitor monotherapy significantly lowered actionable bleeding (2.6% vs 5.6%, P = .002) without increasing major adverse events (2.1% vs 2.2%). In contrast, the NEO-MINDSET trial found that withdrawing aspirin very early—within four days after PCI—reduced bleeding (2.0% vs 4.9%) but did not achieve non-inferiority for ischemic outcomes (MAE 7.0% vs 5.5%). These results reaffirm that at least one month of DAPT remains necessary following ACS.
Among post-CABG patients in TACSI, ticagrelor plus aspirin did not lower ischemic events compared with aspirin alone but doubled major bleeding risk (4.9% vs 2.2%). Meanwhile, the CELEBRATE trial highlighted the value of early pharmacologic platelet inhibition, demonstrating that pre-hospital subcutaneous zalunfiban improved coronary perfusion (P = .012) and 30-day hierarchical outcomes (P = .028), with only a modest increase in mild-to-moderate bleeding.
In AF management, the AQUATIC trial reported that adding aspirin to oral anticoagulation (OAC) in stable chronic coronary syndrome increased major adverse events (16.9% vs 12.1%), major bleeding (10.2% vs 3.4%), and mortality. Similarly, ADAPT AF-DES confirmed that OAC monotherapy beyond 12 months after stenting is superior.
In frail elderly patients, COMBINE-AF demonstrated that switching from warfarin to a direct oral anticoagulant (DOAC) reduced intracranial hemorrhage (0.38%/year vs 1.33%/year) and fatal bleeding, though gastrointestinal bleeding increased. PRESTIGE-AF further illustrated the complexity of anticoagulation after intracerebral hemorrhage: DOAC therapy significantly reduced ischemic stroke (0.83%/year vs 8.60%/year) but raised the risk of recurrent ICH (5.0%/year vs 0.82%/year), emphasizing the importance of individualized decision-making.
In valvular heart disease, ENBALV showed similar short-term outcomes with edoxaban and warfarin following bioprosthetic valve surgery. A randomized pilot study in mechanical valve thrombosis also reported lower in-hospital and one-year mortality with prolonged low-dose fibrinolysis compared with urgent surgery.
Overall, 2025 evidence reinforces a precision-based approach to antithrombotic therapy—carefully balancing ischemic protection against bleeding risk through patient-centered, context-specific pharmacologic strategies.
