Milvexian: evaluating the factor XIa inhibitor for the treatment of acute coronary syndrome.

Balancing the prevention of thrombosis with bleeding risk when combining anticoagulants and platelet antagonists remains a concern among clinicians, particularly in patients with acute coronary syndrome (ACS) who are treated with potent antiplatelet therapy. This may be because the available antiplatelet and anticoagulants are unable to uncouple physiological hemostasis and pathological thrombosis. Therefore, their use is associated with an unavoidable elevated risk of bleeding. Evidence available from studies evaluating FXIa inhibitors and milvexian were collected from a selective literature search. In this review, the authors describe the potential role of FXI/XIa in experimental thrombosis, evidence for FXIa inhibition in the treatment of clinical thrombotic events and highlight the current evidence supporting the role of milvexian, a novel FXIa inhibitor, in patients with ACS. The ongoing LIBREXIA-ACS trial is the large-scale study currently investigating milvexian in patients with ACS. This study may support the proof of concept of differentiating physiological hemostasis and pathological thrombosis and achieving maximum antithrombotic efficacy with minimum bleeding risk when used on top of DAPT with potent P2Y