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© Author(s) (or their employer(s)) 2023. No commercial reuse. See rights and permissions. Published by BMJ. INTRODUCTION Antithrombotic therapy is the cornerstone of the pharmacological treatment in patients with established coronary artery disease (CAD). Despite technological improvements, the refinement of interventional strategies and more effective pharmacological treatments, patients with CAD remain at high risk of ischaemic recurrences at shortterm and longterm. Although antithrombotic treatment intensification lowers ischaemic complications compared with less potent regimens, it increases the risk of major bleeding events which carry a similar or even worse prognostic impact than a recurrent myocardial infarction (MI). The mounting awareness of the prognostic relevance of bleeding complications led to some paradigm shifts in the antithrombotic treatment of patients with CAD. In the last decade, evidence continued to evolve and different treatment regimens in various combinations and durations have been tested in patients at high ischaemic and/or bleeding risk. However, the risk of adverse events in patients with CAD may not be uniform over time with the highest risk of ischaemic events in the first 1–3 months after the index event, followed by a slight prevalence of the bleeding risk over time (figure 1). The identification of patient profiles and various risk combinations over time (ie, those with concomitant high bleeding and thrombotic risk) together with a better understanding of potential mechanisms responsible for either higher or lower individual response to antithrombotic agents paved the way forward to tailored approaches aimed at mitigating bleeding complications while preserving therapeutic efficacy, including abbreviated dual antiplatelet therapy (DAPT), P2Y12 monotherapy and deescalation strategies. The aim of this Education in Heart paper is to provide an update of available evidence on antithrombotic treatment regimens for secondary or tertiary prevention in patients with established CAD based on different ischaemic and/or bleeding risk profiles. Since the choice and duration of antithrombotic therapy may vary according to clinical presentation and revascularisation modality, the summary and interpretation of the evidence will be provided separately for patients with acute coronary syndrome (ACS) or chronic coronary syndrome (CCS) managed by percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG) or medical treatment alone. In line with European Society of Cardiology (ESC) guidelines, we will separately appraise antithrombotic strategies for patients with CCS who never experienced a prior MI as well as those with stabilised CCS at 12 months after an ACS event. Antithrombotic strategies in patients with CAD with indication for oral anticoagulation have been addressed in multiple guidelines and consensus papers and are therefore not covered by the present document.