Guided de-escalation of antiplatelet treatment in patients at high atherothrombotic risk presenting with acute coronary syndrome: a post hoc analysis of the TROPICAL-ACS trial
Authors' conclusion
Early PFT-guided de-escalation from prasugrel to clopidogrel was safe across atherothrombotic risk categories, supporting individualized DAPT optimization in ACS patients with both low and high ischaemic risk.
Study context
- Population
- Acute coronary syndrome (ACS) patients randomized to standard prasugrel therapy or platelet function testing (PFT)-guided DAPT de-escalation, stratified by atherothrombotic risk (ATR)ACS patients randomized · High ATR 990 · Low ATR 1,620
- Participants
- 2,610 patients
- Comparison
- PFT-guided DAPT de-escalation vs standard 12-month prasugrel therapy, according to ATR status
- High ATRn = 990
- Low ATRn = 1,620reference
- Primary endpoint
- Net clinical benefit: composite of cardiovascular death, myocardial infarction, stroke, or Bleeding Academic Research Consortium 2-5 bleeding
Methodological detailsrandomized, stratified by ATR, multistate Cox regression
- Randomized
- Stratified by ATR
- Multistate Cox regression
Primary result
As reported in the abstract
Hazard ratio (95% CI)P value
High ATR vs Low ATR
1.67(1.28–2.18)
P < 0.001PFT-guided DAPT de-escalation vs standard 12-month prasugrel therapyhigh ATR: 10.5% vs. 11.5%
0.90(0.61–1.32)
P = 0.586PFT-guided DAPT de-escalation vs standard 12-month prasugrel therapylow ATR: 5.6% vs. 7.7%
0.71(0.48–1.04)
P = 0.082Further findings
| Outcome | High ATR | Low ATR | PFT-guided DAPT de-escalation | Standard 12-month prasugrel therapy | HR (CI) | |
|---|---|---|---|---|---|---|
| Ischaemic eventsHigh ATR | Not reported in the abstract | Not reported in the abstract | 3.7% | 4.4% | 0.83 (0.44–1.56) | High ATR, Low ATR: not reported in the abstract |
| Ischaemic eventsLow ATR | Not reported in the abstract | Not reported in the abstract | 1.8% | 2.6% | 0.68 (0.35–1.34) | High ATR, Low ATR: not reported in the abstract |
| 0.20.5125Hazard ratio (log scale) |
- Ischaemic events: Pinteraction = 0.666
Original publication
Guided de-escalation of antiplatelet treatment in patients at high atherothrombotic risk presenting with acute coronary syndrome: a post hoc analysis of the TROPICAL-ACS trial. Eur Heart J Acute Cardiovasc Care. Published 26 December 2025. doi:10.
Summarised from the published abstract; every number is checked against it