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Antithrombotic therapy represents the cornerstone of the pharmacological treatment in patients with acute coronary syndrome (ACS). The optimal combination and duration of antithrombotic therapy is still matter of debate requiring a critical assessment of patient comorbidities, clinical presentation, revascularization modality, and/or optimization of medical treatment. The 2023 European Society of Cardiology (ESC) guidelines for the management of patients with ACS encompassing both patients with and without ST segment elevation ACS have been recently published. Shortly before, a European expert consensus task force produced guidance for clinicians on the management of antithrombotic therapy in patients with ACS as well as chronic coronary syndrome. The scope of this manuscript is to provide a critical appraisal of differences and similarities between the European consensus paper and the latest ESC recommendations on oral antithrombotic regimens in ACS patients.

Multiple guidelines and consensus papers have addressed the role of antithrombotic strategies in patients with established coronary artery disease (CAD). Since evidence and terminology continue to evolve, the authors undertook a consensus initiative to guide clinicians to select the optimal antithrombotic regimen for each patient. The aim of this document is to provide an update for clinicians on best antithrombotic strategies in patients with established CAD, classifying each treatment option in relation to the number of antithrombotic drugs irrespective of whether the traditional mechanism of action is expected to mainly inhibit platelets or coagulation cascade. With the aim to reach comprehensiveness of available evidence, we systematically reviewed and performed meta-analyses by means of both direct and indirect comparisons to inform the present consensus document.Graphical AbstractAlgorithm for antithrombotic treatment in patients with established CAD. Treatment preferences within each box are shown from above to below, whereas treatments within the same line are sorted in alphabetical order. Panels A and B refer to non-high bleeding risk (HBR) and HBR patients, respectively. HBR is defined according to the ARC-HBR criteria or a PRECISE-DAPT score ≥25. * for patients at high ischaemic risk and very low bleeding risk. § if the patient is not eligible for above shown treatment options. Box colours indicate composition of antithrombotic regimens (light blue: SAPT; grey: DAPT; and red: DAT). Abbreviations: ARC, Academic Research Consortium; CABG, coronary artery bypass grafting; CAD, coronary artery disease; DAPT, dual antiplatelet therapy; DAT, dual antithrombotic therapy; MI, myocardial infarction; PCI, percutaneous coronary intervention; SAPT, single antiplatelet therapy.

Graphical AbstractThe two best-in-class treatments for each outcome. Number needed to treat (NNT) and number needed to harm (NNH) with 95% confidence intervals were generated from the within and beyond 12 months network meta-analyses (NMAs) and adjusted according to baseline risk profile (low and high risks). Best-in-class antithrombotic regimens for patients at high and low risk of all-cause mortality, myocardial infarction, stroke, or major bleeding are presented in hierarchical order in terms of net benefit (NNH/NNT ratio). The average follow-up for the within and beyond 12 months NMA was 12 and 30 months, respectively. * denotes statistically significant differences in the NMA.

Supplemental Digital Content is Available in the Text.Despite large-scale randomized clinical trials (RCTs) highlighting a consistent prognostic benefit of sodium–glucose cotransporter 2 inhibitors (SGLT2is) both in diabetic patients at high cardiovascular risk and in those with heart failure, there is relative paucity of data on their biochemical effects in a real-world setting. We performed a retrospective analysis on consecutive diabetic patients who were prescribed a SGLT2i in a tertiary referral center and completed at least 1 year of treatment. Changes in glycated hemoglobin, weight, and hematocrit were compared across 2 cardiovascular risk categories, defined through the inclusion criteria of 3 large RCTs. Of the 459 patients screened, 312 completed 1 year of treatment (68.0%), 92 interrupted the treatment prematurely (20.0%), and 55 were lost to follow-up (12.0%). The most common cause of drug discontinuation was genital or urinary tract infections (9.4%). At 1 year, reduction in glycated hemoglobin concentration (−0.7 ± 1.5%, P< 0.001) and body weight (2.4 ± 4.6 kg, P< 0.001) was comparable between patients at high versus low cardiovascular risk, while hematocrit increase (2.3 ± 3.3%, P< 0.001) was more marked in patients with high cardiovascular risk and low baseline hematocrit. In a real-world population of diabetic patients, SGLT2is were well-tolerated at 1 year and led to improved glycemic control and weight loss. Hematocrit increase was more consistent in patients with high cardiovascular risk and signs of fluid overload, indicating euvolemic restoration as a potential cardioprotective mechanism mediated by these compounds.