Acute Coronary Syndrome, Antiplatelet Therapy, and Bleeding: A Clinical Perspective

Abstract

Inhibition of platelet function by means of dual antiplatelet therapy (DAPT) is the cornerstone of treatment of acute coronary syndrome (ACS). While preventing ischemic recurrences, inhibition of platelet function is clearly associated with an increased bleeding risk, a feared complication that may lead to significant morbidity and mortality. Since bleeding risk management is intrinsically associated with therapeutic adjustments undertaken during the whole clinical history of patients with acute coronary syndrome, single decisions taken from the very first day to years of follow-up might be decisive. This review aims at providing a clinically oriented, patient-tailored approach in reducing the risk and manage bleeding complications in ACS patients treated with DAPT. The steps in clinical decision making from the day of ACS to follow-up are analyzed. New treatment strategies to enhance the safety of DAPT are also described.

Keywords: P2Y12 inhibition; acute coronary syndrome; bleeding; clopidogrel; dual antiplatelet therapy; high bleeding risk; prasugrel; tailored therapy; ticagrelor.

Figure 1

Critical points in decision making when choosing an antiplatelet strategy and managing related bleedings. PCI, percutaneous coronary intervention; DAPT, dual antiplatelet therapy; ACS, acute coronary syndrome; HBR, high bleeding risk; PPI, proton pump inhibitors.