Jul 2026· Journal of Basic and Clinical Physiology and Pharmacology· 0 citations· 146 references
Medicine
TL;DR
Evidence suggests that genotype-guided therapy, PFT-guided treatment, and individualized DAPT duration may improve the balance between ischemic protection and bleeding risk in selected high-risk populations, but routine implementation remains limited by inconsistent clinical outcome benefits.
Abstract
Abstract Dual antiplatelet therapy (DAPT), combining aspirin with a P2Y12 inhibitor, remains central to secondary prevention after acute coronary syndrome and percutaneous coronary intervention. However, substantial interindividual variability in antiplatelet response, particularly clopidogrel resistance associated with CYP2C19 polymorphisms, has challenged the conventional “one-size-fits-all” approach and increased interest in precision-guided antiplatelet strategies. This narrative review synthesized literature identified through PubMed, Scopus, Web of Science, and Google Scholar, focusing on randomized trials, genotype-guided studies, platelet function testing (PFT), meta-analyses, guideline statements, and emerging artificial intelligence (AI)-based prediction models. Evidence suggests that genotype-guided therapy, PFT-guided treatment, and individualized DAPT duration may improve the balance between ischemic protection and bleeding risk in selected high-risk populations. However, routine implementation remains limited by inconsistent clinical outcome benefits, heterogeneous testing strategies, modest risk-score performance, cost, infrastructure barriers, and variable guideline recommendations. Precision-guided DAPT is promising, but broader adoption requires stronger prospective evidence, standardized testing pathways, and real-world validation.
Individualized DAPT de-escalation, guided by dynamic risk assessment using PRECISE‑DAPT and ARC-HBR criteria, optimizes net clinical benefit and should focus on precision antithrombotic strategies in Chinese populations and high-risk subgroups.
Antithrombotic therapy after percutaneous coronary intervention (PCI) is shifting from fixed 12‐month dual antiplatelet therapy (DAPT) to risk‐stratified, patient‐centered regimens. In this systematic review (80 studies; >330,000 patients), we compare personalized versus fixed DAPT strategies, evaluate abbreviated DAPT in high‐bleeding‐risk (HBR) populations, and evaluate bleeding and ischemic risk scores. Personalized strategies, including genotype‐guided therapy, ultra‐short DAPT (≤1 month) with P2Y12 monotherapy, and 3‐month DAPT, substantially reduce bleeding (often by roughly 25%−65%); ischemic risk after de‐escalation is heterogeneous across populations and strategies, with most trials showing neutrality and one (STOPDAPT‐2 ACS) signaling increased myocardial infarction (MI) when aspirin was withdrawn after 1–2 months of clopidogrel‐based DAPT in acute coronary syndrome (ACS). In HBR patients, 1 to 3‐month DAPT followed by P2Y12 monotherapy lowers major bleeding by up to 65% and may reduce cardiovascular mortality, without increased MI or stent thrombosis in most trials, although ischemic signals varied by population and strategy. In atrial fibrillation, avoiding prolonged triple therapy reduces bleeding by approximately 30%. In ACS, prasugrel is favored over ticagrelor for ischemic outcomes; ARC‐HBR, PRECISE‐DAPT, and the newer PRECISE‐HBR scores show moderate discrimination (c‐statistic 0.64–0.75). Contemporary data therefore support replacing one‐size‐fits‐all 12‐month DAPT with risk‐guided algorithms for post‐PCI antithrombotic therapy.
Thierry Kochkarian, Anis Ismail, Omar Chaabo et al.· Catheterization and cardiova...· 0 citations
Abstract Current evidence indicates that antiplatelet therapy as a cornerstone for secondary prevention of cerebral infarction. However, ischemic or bleeding events arising from antiplatelet drug resistance or excessive platelet inhibition can diminish its clinical benefit. These challenges have laid the foundation for individualized antiplatelet treatment. Although cytochrome P450 family 2 subfamily C member 19 (CYP2C19) genetic polymorphisms have partially addressed the issue of drug resistance in these patients, they remain insufficient to resolve the high incidence of both ischemic and bleeding events. Platelet function testing (PFT)‐guided antiplatelet therapy has been proven beneficial in patients after percutaneous coronary intervention, yet its efficacy in patients with cerebral infarction remains controversial. Platelet function provides a direct and comprehensive reflection of antiplatelet effects, offering potential not only to overcome drug resistance but also to guide de‐escalation strategies, thereby mitigating the frequent occurrence of both ischemic and bleeding events in cerebral infarction. Overall, the current application of PFT to guide personalized antiplatelet regimens in patients with cerebral infarction is characterized by considerable variability. In light of recent advances in this field, we herein review the current landscape of PFT‐guided individualized antiplatelet therapy in cerebral infarction, with the aim of summarizing existing evidence and offering suggestions for future research.
The principal challenge in modern HFrEF management is no longer the absence of effective therapies, but failure to deliver proven therapies rapidly, comprehensively, and sustainably.
Ehsan Shahverdi, Amin Shahverdi, Sendooran Shahi et al.· Journal of the Saudi Heart A...· 0 citations
This is the first systematic review and meta-analysis to combine an updated quantitative synthesis of functional clopidogrel resistance with a dedicated qualitative appraisal of CYP2C19 genetic determinants, while explicitly separating analyses based on raw event data from exploratory analyses using published effect estimates and applying conservative small-sample sensitivity methods.
M. L. Del Rio-Sola, Sandra Pérez-Fernández, Marina Jiménez-Caja et al.· Clinical Therapeutics· 0 citations
The landscape of lipid management has transitioned from a statin-monotherapy and statin-intensification paradigm to a sophisticated, multi-axis intervention model targeting low-density lipoprotein cholesterol, triglyceride-rich lipoproteins, lipoprotein(a), and vascular inflammation. The emergence of PCSK9-targeted small interfering RNA therapies, CETP inhibitors, and Lp(a)-directed antisense and RNA based agents has enabled complementary modulation of diverse lipid pathways through distinct molecular targets. However, this increasingly multidrug approach may also increase treatment complexity, healthcare burden, and adherence challenges, particularly among high-risk patients already receiving multidrug cardiometabolic therapy. Although intensive and sustained LDL-C lowering remains foundational to preventive cardiology, the real-world effectiveness of increasingly complex treatment strategies may ultimately depend on long-term adherence, affordability, patient capacity, and implementation feasibility. We propose a Clinical Prioritization and Personalization Framework centered on individualized risk-based intensification, comprehensive residual risk management, and optimization of treatment delivery to achieve sustainable, patient-centered cardiovascular protection.
Yashendra Sethi, K. Mahajan, Michael D. Shapiro et al.· Progress in cardiovascular d...· 1 citation
