Current Strategies for Optimizing Antithrombotic Therapy in Patients with Chronic Coronary Syndrome: A Dynamic Approach

Chronic coronary syndrome (CCS) represents a heterogeneous and dynamic manifestation of coronary artery disease characterized by persistent atherosclerotic burden and ongoing risk of atherothrombotic events. Antithrombotic therapy remains a cornerstone of secondary prevention in CCS, yet optimal treatment strategies have evolved substantially in recent years. The 2024 European Society of Cardiology (ESC) guidelines provide updated recommendations that reflect emerging evidence from randomized clinical trials and meta-analyses evaluating antiplatelet and anticoagulant strategies. This narrative review summarizes key updates in the 2024 ESC CCS guidelines and the clinical evidence underpinning these changes. Contemporary management has moved beyond a uniform antithrombotic approach toward individualized treatment strategies based on ischemic and bleeding risk. Single antiplatelet therapy remains the foundation of long-term management, although clopidogrel is now recognized as a Class I, Level A alternative to aspirin in selected patients. For patients undergoing percutaneous coronary intervention (PCI), the guideline maintains a default strategy of 6 months of dual antiplatelet therapy (DAPT) while providing stronger recommendations for abbreviated DAPT in patients at high bleeding risk. Emerging evidence supporting de-escalation strategies and early aspirin withdrawal following PCI has further contributed to risk-adapted treatment pathways. Conversely, in patients with persistently high ischemic risk and low bleeding risk, intensified strategies-including prolonged DAPT, ticagrelor-based therapy, or dual pathway inhibition with low-dose rivaroxaban and aspirin-may provide additional protection against recurrent ischemic events. The updated recommendations underscore the importance of patient-centered risk stratification and periodic reassessment of ischemic and bleeding risk. Integrating clinical judgment with structured tools such as ARC-HBR and PRECISE-DAPT enables clinicians to tailor antithrombotic therapy in CCS, optimizing net clinical benefit in routine practice.