Antithrombotic treatment following percutaneous coronary intervention in patients with high bleeding risk

Abstract

Purpose of review: Review the clinical outcomes of different antithrombotic strategies in patients with high bleeding risk (HBR) after percutaneous coronary intervention (PCI).

Recent findings: Patients with HBR after PCI include those with advanced age (e.g. >75 years of age), a prior history of major bleeding, anemia, chronic kidney disease, and those with indications for long-term anticoagulation. Strategies that successfully decrease bleeding risk in this population include shorter durations of dual antiplatelet therapy (DAPT; of 1-3 months) followed by single antiplatelet therapy with aspirin or a P2Y 12 inhibitor, or de-escalating from a more potent P2Y 12 inhibitor (prasugrel or ticagrelor) to less potent antiplatelet regimens (aspirin with clopidogrel or half-dose ticagrelor or half-dose prasugrel). Patients on DAPT, and a full dose anticoagulation for other indications, have a lower risk of major bleeding without an increase in 1-2-year adverse ischemic events, when rapidly switched from DAPT to a single antiplatelet therapy (within a week after PCI) with aspirin or clopidogrel. Longer term data on the benefits and risks of these strategies is lacking.

Summary: In patients with HBR after PCI, shorter durations of DAPT (1-3 months) decrease the risk of major bleeding without increasing the risk of adverse ischemic events.

FIGURE 1.

Proposed antithrombotic therapy selection algorithm in patients with high bleeding risk after percutaneous coronary intervention according to the indication for percutaneous coronary intervention or use of long-term anticoagulation. *DOACs preferred over VKA. DAPT, dual antiplatelet therapy; OAC, oral anticoagulant; SAPT, single antiplatelet therapy.