Antiplatelet therapy for treatment of coronary artery disease in older patients

[Display omitted] •Bleeding and ischaemic risks must be assessed rigorously before and after PCI.•DAPT can be reduced to 1 month after PCI in patients at HBR treated for CCS.•DAPT can be reduced to 1–3 months after PCI in patients at HBR treated for ACS.•P2Y12 inhibitors could be replaced by less potent inhibitors in de-escalation.•After initial DAPT, SAPT (clopidogrel or ticagrelor) could be prescribed.•Antiplatelet therapy must be combined with a PPI to reduce bleeding.•In those requiring oral anticoagulation, TAT could be reduced to≤1 week. Coronary artery disease in older patients is more frequently diffuse and complex, and is often treated by percutaneous coronary intervention on top of medical therapy. There are currently no specific recommendations for antiplatelet therapy in patients aged≥75 years. Aspirin remains pivotal, and is still indicated as a long-term treatment after percutaneous coronary intervention. In addition, a P2Y12 inhibitor is administered for 6–12 months according to clinical presentation. Age is a minor bleeding risk factor, but because older patients often have several co-morbidities, they are considered as having a high bleeding risk according to different scoring systems. This increased bleeding risk has resulted in different therapeutic strategies for antithrombotic treatment after percutaneous coronary intervention; these include short dual antiplatelet therapy, a switch from potent to less potent antiplatelet therapy or single antiplatelet therapy with a P2Y12 inhibitor instead of aspirin, among others. A patient-centred approach, taking into account health status, functional ability, frailty, cognitive skills, bleeding and ischaemic risks and patient preference, is essential when caring for older adults with coronary artery disease. The present review focuses on the knowledge base, specificities of antiplatelet therapies, a balance between haemorrhagic and ischaemic risk, strategies for antiplatelet therapy and directions for future investigation pertaining to coronary artery disease in older patients.