Controversies in Antiplatelet and Anticoagulation Therapy in Patients Presenting with Acute Coronary Syndrome

Multiple, large-scale pharmaceutical and device trials have greatly improved the outcomes of patients with acute coronary syndrome (ACS). The expanding arsenal of antiplatelets, anticoagulants, and coronary stents has simultaneously generated debate over how to best optimize ischemic outcomes while mitigating bleeding risk for individual patients. This manuscript reviews the data supporting current practice, and highlights areas where the data are weak and controversies abound. After introducing the background and pathophysiology of patients presenting with ACS, five clinical controversies relevant to the everyday care of the ACS patient are discussed: (1) choice initial antiplatelet and anticoagulant combination; (2) decision to start second oral antiplatelet before or after coronary angiography; (3) transition between antiplatelets; (4) duration of dual antiplatelet therapy; and (5) management of patients on oral anticoagulants.