Antiplatelet therapy: indications and limitations in the elderly population

Recent antiplatelet agents such as prasugrel and ticagrelor provide a benefit in reducing ischemic events in the setting of acute coronary syndromes. These drugs, like clopidogrel, increase the risk of bleeding when combined with aspirin and their use in elderly or very elderly patients is challenging. Patients aged over 75 with acute coronary syndrome (ACS) should also be offered the combination of aspirin and ticagrelor or clopidogrel with the appropriate loading doses. It is recommended to avoid prasugrel for this elderly population. Patients with atrial fibrillation and coronary heart disease outside of an acute ischemic event should be anticoagulated without the addition of antiplatelet agents. In patients at high risk of coronary thrombosis a combination of drugs may be discussed. The existence of a severe bleeding history in elderly patients may require shorter duration of antiplatelet associations and even the principle of these associations may be challenged, taking into account their risk-benefit ratio in the individual context. Last generation coronary stents will certainly contribute to the modulation of the antiplatelet regimen, especially in high bleeding risk patients such as the elderly population.