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Achieving effective platelet inhibition and anticoagulation, with minimal risk, is particularly important in high-risk ACS patients, especially those with cardiogenic shock (CS) or those successfully resuscitated following out-of-hospital cardiac arrest (OHCA), who have a 30-50% risk of death or a recurrent ischaemic event over the subsequent 30 days. There are unique challenges to achieving effective and safe antithrombotic treatment in this cohort of patients that are not encountered in most other ACS patients. This position paper focuses on patients presenting with CS or immediately post-OHCA, of presumed ischaemic aetiology, and examines issues related to thrombosis and bleeding risk. Both the physical and pharmacological impacts of CS, namely impaired drug absorption, metabolism, altered distribution and\/or excretion, associated multiorgan failure, co-morbidities and co-administered treatments such as opiates, targeted temperature management, renal replacement therapy and circulatory or left ventricular assist devices, can have major impact on the effectiveness and safety of antithrombotic drugs. Careful attention to the choice of antithrombotic agent(s), route of administration, drug-drug interactions, therapeutic drug monitoring and factors that affect drug efficacy and safety, may reduce the risk of sub- or supra-therapeutic dosing and associated adverse events. This paper provides expert opinion, based on best available evidence, and consensus statements on optimising antithrombotic therapy in these very high-risk patients, in whom minimising the risk of thrombosis and bleeding is critical to improving outcome.<\/jats:p>","DOI":"10.1093\/ehjcvp\/pvaa009","type":"journal-article","created":{"date-parts":[[2020,2,4]],"date-time":"2020-02-04T15:09:42Z","timestamp":1580828982000},"page":"125-140","source":"Crossref","is-referenced-by-count":64,"title":["Antithrombotic therapy in patients with acute coronary syndrome complicated by cardiogenic shock or out-of-hospital cardiac arrest: a joint position paper from the European Society of Cardiology (ESC) Working Group on Thrombosis, in association with the Acute Cardiovascular Care Association (ACCA) and European Association of Percutaneous Cardiovascular Interventions (EAPCI)"],"prefix":"10.1093","volume":"7","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9286-1451","authenticated-orcid":false,"given":"Diana A","family":"Gorog","sequence":"first","affiliation":[{"name":"Department of Medicine, National Heart & Lung Institute , Imperial College, London, UK"},{"name":"Postgraduate Medical School, University of Hertfordshire , Hatfield, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Susanna","family":"Price","sequence":"additional","affiliation":[{"name":"Department of Medicine, National Heart & Lung Institute , Imperial College, London, UK"},{"name":"Intensive Care Unit, Royal Brompton Hospital , London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dirk","family":"Sibbing","sequence":"additional","affiliation":[{"name":"Ludwig-Maximilians-Universit\u00e4t, M\u00fcnchen, Medizinische Klinik und Poliklinik I, Campus Gro\u00dfhadern , M\u00fcnchen, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7707-2254","authenticated-orcid":false,"given":"Andreas","family":"Baumbach","sequence":"additional","affiliation":[{"name":"Barts Heart Centre, William Harvey Research Institute, Bartshealth NHS Trust, Queen Mary University of London , West Smithfield, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Davide","family":"Capodanno","sequence":"additional","affiliation":[{"name":"Division of Cardiology, A.O.U. \u201cPoliclinico-Vittorio Emanuele\u201d, University of Catania , Catania, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bruna","family":"Gigante","sequence":"additional","affiliation":[{"name":"Unit of Cardiovascular Medicine, Department of Medicine, Karolinska Institutet , Stockholm, Sweden"},{"name":"Department of Clinical Science, Danderyds Hospital , Danderyd, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sigrun","family":"Halvorsen","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Oslo University Hospital Ulleval , University of Oslo, Oslo, Norway"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kurt","family":"Huber","sequence":"additional","affiliation":[{"name":"3rd Department of Medicine, Cardiology and Intensive Care Medicine , Wilhelminenhospital, Vienna, Austria"},{"name":"Sigmund Freud University, Medical School , Vienna, Austria"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0146-9196","authenticated-orcid":false,"given":"Maddalena","family":"Lettino","sequence":"additional","affiliation":[{"name":"Cardio-Thoracic and Vascular Department, San Gerardo Hospital , ASST-Monza, Monza, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sergio","family":"Leonardi","sequence":"additional","affiliation":[{"name":"Coronary Care Unit, University of Pavia and Fondazione IRCCS Policlinico S. 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