Type and duration of antithrombotic therapy after treatment of severely calcified lesions

The presence of coronary artery calcification (CAC) increases with age, leading to a higher number and complexity of percutaneous coronary intervention (PCI) procedures in older patients. Chronic kidney disease (CKD) and diabetes are also associated with the development of CAC. These significant comorbidities, combined with PCI of severely calcified lesions, pose major challenges due to technical difficulties and potentially compromise both short- and long-term outcomes. Patients undergoing PCI for heavily calcified lesions should receive optimal anticoagulation and antiplatelet therapy according to current guidelines. However, data on the potential use of more potent P2Y12 inhibitors (ticagrelor, prasugrel) instead of clopidogrel as standard practice in elective PCI of CAC are limited. This is due to varying classifications used to define complex PCI in meta-analyses, and the extreme heterogeneity of the populations studied in terms of clinical presentation. The duration of antiplatelet therapy with aspirin and a P2Y12 inhibitor can be prolonged in selected patients. However, there is increasing evidence supporting the validity of P2Y12 inhibitor monotherapy after standard DAPT, adopting an aspirin-free and tailored de-escalation strategy.