The 2014 European Society of Cardiology (ESC) guidelines recommend 12 months of dual antiplatelet therapy (DAPT) favouring combination of aspirin and prasugrel or aspirin and ticagrelor over aspirin and clopidogrel after acute coronary syndrome (ACS).1 The rationale behind these recommendations is based on prospective randomised trials investigating the efficacy of both combinations against aspirin and clopidogrel. The risk-to-benefit ratios of these strategies were estimated from clinical trials investigating their efficacy on major cardiovascular events and their safety on major bleeding events.1 Not surprisingly, both new P2Y12 inhibitors induced more bleeding, but with different patterns. In ST-segment elevation myocardial infarction (STEMI) patients, most frequent fatal bleeding events with prasugrel were particularly noticeable in older or underweight patients and in those with previous cerebrovascular disease. Ticagrelor increased the risk of non-coronary artery bypass graft (CABG)-related major bleeding events, including fatal intracranial bleeding.

Klingenberg et al2 now report in their Heart paper the results of a recent Swiss cohort study investigating ‘in real life’ the safety profile of prasugrel and clopidogrel, both combined with aspirin, after ACS. In their study data, 2148 patients were analysed using a propensity score to assess and compare 1-year safety. No significant differences were observed between antiplatelet regimen regarding major bleeding, regardless of the classification used: TIMI, GUSTO and BARC. Patients receiving clopidogrel were significantly older, more likely to be women, and more likely to have diabetes and chronic renal failure. Patients receiving prasugrel had significantly more STEMI at clinical presentation and had more stent implantation during the index procedure. As expected, …