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Residual ischaemic risk after an acute coronary syndrome (ACS) remains high despite coronary revascularisation and current guideline-based secondary prevention. More potent antithrombotic strategies—such as prolonged dual antiplatelet therapy (DAPT),1 use of potent P2Y12 inhibitors,2 or combination of a low-dose anticoagulant and aspirin3—have recently been proposed. Each of these strategies not only reduces ischaemic risk, but also increases bleeding risk.
In parallel, knowledge on the impact of bleeding on prognosis in patients with coronary artery disease is increasing. As a consequence, maintaining a low bleeding risk is now of utmost importance in this population. This trend is attested by the fact that a growing number of randomised clinical trials have now bleeding rather than ischaemic events as primary endpoints.4
The selection of patients likely to derive benefit from potent antithrombotic strategies with acceptable bleeding risk therefore requires concomitant evaluation of ischaemic and bleeding risks.
In this issue of Heart, Lindholm et al 5 assessed the effects of combining key clinical risk factors on the recurrent ischaemic and bleeding risks after acute myocardial infarction (MI). To do this, they studied the SWEDEHEART registry, which included more than 100 000 patients admitted for MI. The key risk factors used in their model have been proven to be associated with worse outcomes in this population as they increase ischaemic …
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