• Coronary artery disease
• Acute coronary syndromes

Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 antagonist improves cardiovascular outcomes in patients with acute coronary syndrome but at a cost of an increased risk of bleeding complications.1 There is marked variability in the thrombotic and bleeding risk between individuals with multiple patient and procedural factors identified but not yet fully understood. Generic recommendations for DAPT duration inevitably expose some patients to an excessive duration of treatment and bleeding risk while simultaneously disadvantaging other patients by withdrawing therapy that could protect them from atherothrombotic events. This is increasingly recognised as a major clinical problem, and current European and North American Acute Coronary Syndromes (ACS) guidelines now acknowledge that shorter durations of DAPT may be considered in patients at high risk of bleeding while extended treatment (>12 months) is an option in selected patients. To implement these guideline recommendations, robust prediction tools are required to facilitate the accurate identification of individuals who are more or less likely to benefit from shorter or longer durations of treatment.

The association between bleeding and mortality has been a consistent feature of acute coronary syndrome trials, irrespective of the intervention being assessed. The present paper by Alfredsson and colleagues2 fills an important gap since it provides the first longitudinal long-term bleeding risk score (0–30 months) for medically managed ACS patients treated with DAPT. Previous post-ACS bleeding risk tools have informed on short-term bleeding risk in patients predominantly managed with percutaneous coronary intervention3–5 or at a single time point (2 years) in a population with a majority of stable coronary artery disease (~70%).6 From 12 preselected candidate variables and using the Targeted Platelet Inhibition to Clarify the Optimal Strategy to Medically Manage (TRILOGY) ACS study database, the authors identified 10 baseline predictors of Global Use of Strategies to Open Occluded Arteries …