LAUSR

This Focus Issue on thrombosis and antithrombotic treatment contains the State of the Art Review article ‘Towards personalized antithrombotic management with drugs and devices across the cardiovascular spectrum’ by Thomas Lüscher from the Royal Brompton & Harefield Hospitals in London, UK, and colleagues. The authors note that intravascular thrombus formation and embolization are among themost frequent events leading to a number of cardiovascular conditions with high morbidity and mortality. Personalized anticoagulation must consider the clinical context, the patient characteristics (including genetics where appropriate), the expected efficacy vs. risk of bleeding related to different antithrombotic medications, and the patient’s preference. The fact that inmany patients, several clinical conditions such as acute coronary syndrome (ACS), atrial fibrillation, valvular heart disease, and/or peripheral or carotid artery disease may co-exist complicatesmatters substantially. Unfortunately, many trials have excluded such multimorbid patients and hence the evidence is somewhat limited in this setting. Particularly challenging situations are patients with cerebral bleeding and ACS undergoing a percutaneous coronary intervention. Similarly, some patients may receive several devices simultaneously or in staged procedures. Undoubtedly, the risk of complications and bleeding might be considerably higher in such patients, requiring good clinical judgement and personalized decision-making within a Heart Team. Finally, patient-centred care has to consider the patient’s interests and preferences, particularly as regards the risks of lifelong antithrombotic medication vs. efficacy and safety of implantable devices. A differential and personalized use of anticoagulants, platelet inhibitors, and devices is recommended and reviewed in this article. Guidelines recommend the use of potent P2Y12 inhibitors over clopidogrel for the reduction of ischaemic events in patients with ACS. However, this comes at the expense of increased bleeding. A guided selection of P2Y12-inhibiting therapy has the potential to overcome this limitation. In a Fast Track Clinical Research article entitled ‘Comparative effects of guided vs. potent P2Y12 inhibitor therapy in acute coronary syndrome: a network meta-analysis of 61 898 patients from 15 randomized trials’, Mattia Galli from the Catholic University of Rome in Italy, and colleagues aimed to evaluate the comparative safety and efficacy of guided vs. routine selection of potent P2Y12-inhibiting therapy in patients with ACS. The authors performed a network meta-analysis of randomized controlled trials (RCTs) comparing different oral P2Y12 inhibitors currently recommended for the treatment of patients with ACS (clopidogrel, prasugrel, and ticagrelor). RCTs including a guided approach (i.e. platelet function or genetic testing) vs. standard selection of P2Y12 inhibitors among patients with ACS were also included. Incidence rate ratios (IRRs) and associated 95% confidence intervals (CIs) were estimated. P-scores were used to estimate hierarchies of efficacy and safety. The primary efficacy endpoint was major adverse cardiovascular events (MACE) and the primary safety endpoint was all bleeding. A total of .61 000 patients from 15 RCTs were included. Clopidogrel was used as reference treatment. A guided approach was the only strategy associated with reduced MACE (IRR 0.80, 95% CI 0.65–0.98) without any significant trade-off in all bleeding (IRR 1.22, 95% CI 0.96–1.55) (Figure 1). The authors conclude that in patients with ACS, compared with routine selection of potent P2Y12-inhibiting therapy (prasugrel or ticagrelor), a guided selection of P2Y12-inhibiting therapy is associated with the most favourable balance between safety and efficacy. These findings support a broader adoption of a guided