We would like to thank both Dr Sharvill and Dr Singh for their valuable comments on our article.1 In terms of gastro-protection, proton pump inhibitors (PPIs) are recommended with dual antiplatelet therapy (DAPT);2 for monotherapy, this depends on individual risk assessment for gastrointestinal bleeding. For clopidogrel alone, lansoprazole is recommended if starting a PPI.
We acknowledge the evolving evidence for shorter DAPT or de-escalation for patients at high risk of bleeding , as shown in our Figure 1. Initial selection and duration are usually the remit of secondary care, with primary care monitoring adherence and complications. I thank Dr Sharvill for also highlighting evolving longer-term evidence that, for secondary prevention, monotherapy clopidogrel is preferential to aspirin.3
For atrial fibrillation patients, direct oral anticoagulants (DOACs) are essential for stroke prevention. The complex decision to combine or discontinue antiplatelets in patients on DOACs is usually specialist guided, balancing thrombotic and bleeding risks.
Our article also outlines a stepwise lipid management approach, with secondary care referral for inclisiran consideration if oral therapies do not meet targets.
We agree that post-acute coronary syndrome review is crucial, representing ‘smarter, proactive care’ and we hope our article can help GPs and primary care teams to formalise and validate this work, emphasising that proper resourcing and clear guidelines are essential for high-quality care.
- © British Journal of General Practice 2025
