Antiplatelet agents in uncertain clinical scenarios—a bleeding nightmare

Abstract

Despite over 40 years since the first percutaneous coronary intervention (PCI) was performed, the optimal dual antiplatelet therapy (DAPT) regime poses a significant challenge for clinicians, especially in certain scenarios. DAPT is the standard of care in PCI following an acute coronary syndrome (ACS) or for elective patients with obstructive coronary artery disease (CAD). There remains significant uncertainty regarding DAPT in patients at high risk of bleeding, such as the elderly and patients requiring anticoagulation. More and more clinicians are faced with a dilemma of weighing risks and benefits from the increasing list of potent, new antiplatelet agents and direct oral anticoagulants (DOACs) in a growing, aging population. Historically, most studies failed to recognize bleeding risk, instead focusing on ischemic risk. In recent years however, bleeding has been recognized as a very significant driver of morbidity and mortality in patients undergoing PCI. There is a paucity of data in this cohort leading to divergent and sometimes conflicting recommendations, largely based on expert consensus of opinion. In the current review, we critically evaluate the available evidence in these uncertain scenarios.

Dual Versus Triple Therapy in Patients with Acute Coronary Syndrome and an Anticoagulation Indication: A Systematic Review with Meta-Analysis and Trial-Sequential Analysis

“…It is important to note that the TT is frequently associated with the interruption of DAPT due to the associated increased bleeding events. 22,23 This may lead to an increase in ischemic complications along with ischemia related to anemia resulting from hemorrhagic episodes. With the use of DOACs, that are proven to reduce bleeding complications compared to warfarin in a variety of settings, it is prudent to expect that ischemic complications may be lowered when added to DAPT.…”

Anticoagulant Use and Bleeding Risk in Central European Patients with Idiopathic Pulmonary Fibrosis (IPF) Treated with Antifibrotic Therapy: Real-World Data from EMPIRE

“…Studies have linked a prothrombotic state with promotion of fibrosis [23,24], and there is strong evidence for avoiding warfarin anticoagulation in patients with IPF [25]. A recent review of antiplatelet therapy found that while bleeding risk was often considered a minor problem, it is associated with an increased risk of mortality and morbidity [26]. Despite this, registry data suggest that anticoagulants/antiplatelet drugs are still prescribed to patients with IPF [27].…”

Ischemic and Bleeding Events in PENDULUM Patients With High Bleeding Risk and High Platelet Reactivity

“…For the comparison of baseline characteristics between HPR and non-HPR subgroups among patients with and without with DAPT. 4,5 To aid physicians in identifying patients at high bleeding risk (HBR), the Academic Research Consortium (ARC) published a consensus document in 2019, which provided a consistent definition of HBR to be used in clinical trials and routine practice to evaluate and standardize treatment. 6 Recent investigations confirmed the applicability of ARC-HBR for identifying bleeding risk in routine clinical practice.…”