Antithrombotic Therapy in High Bleeding Risk for Noncardiac Interventions: Key Points
15 November 2024
Antithrombotic Therapy in High Bleeding Risk for Noncardiac Interventions: Key Points
The following are key points to remember from a state-of-the-art review on antithrombotic therapy in patients with high bleeding risk (HBR) noncardiac percutaneous interventions from the Working Group of Thrombosis of the Italian Society of Cardiology:
- Antithrombotic treatment regimens used in patients undergoing percutaneous cardiac interventions, in particular coronary, are frequently extrapolated to patients undergoing noncardiac interventions. However, the differences in risk profile of the population treated and the types of interventions performed may translate into differences in the safety and efficacy associated with antithrombotic therapy.
- Noncardiac percutaneous interventions are commonly performed in patients at HBR, which may indeed impact outcomes, hence underscoring the importance of risk stratification to guide clinical decision-making processes.
- This document summarizes the available evidence on antithrombotic therapy in HBR patients undergoing noncardiac percutaneous interventions.
- Treatment decisions should be based on patient and procedural characteristics, both of which vary widely in this heterogeneous population.
- The evidence in support of the type and duration of antithrombotic therapy after endovascular revascularization (EVR) in peripheral artery disease patients is modest, particularly for HBR patients. Collectively, available evidence would argue against the use of potent P2Y12 inhibitors (i.e., prasugrel or ticagrelor) or dual pathway inhibition in HBR patients undergoing peripheral EVR, with data more supportive of using short-term (≤1 month) clopidogrel-based dual antiplatelet therapy (DAPT) or single antiplatelet therapy (SAPT), with clopidogrel preferred over aspirin monotherapy, in most cases.
- In patients requiring concomitant oral anticoagulation (OAC), there is no rationale to add antiplatelet therapy in HBR patients with PAD undergoing EVR. Considering that occlusive stent thrombosis is rare, with a reported incidence of 0.5-0.8%, most guidelines recommend OAC alone.
- Patients undergoing carotid artery stenting (CAS) are often deemed to be at HBR due to the risk of postoperative intracranial hemorrhage, which is an often-fatal complication. Collectively, a short course of DAPT (e.g., 1-month) or immediate post-procedural SAPT are reasonable in HBR-CAS patients, while among those with concomitant AF, 1-month dual antithrombotic therapy with OAC plus SAPT or OAC alone are possible therapeutic options.
- Limited data are available on the incidence and predictors of bleeding and consequently risk stratification in patients undergoing percutaneous aortic, renal, subclavian, or mesenteric interventions.
- In these settings, antithrombotic therapy should be selected taking into account a variety of elements including vessel anatomy (e.g., size, location, tortuosity), source of ischemia (e.g., dissection, local thrombosis, thromboembolism), impact on visceral function (e.g., renal, mesenteric, or peripheral district), risk of local recurrence, and systemic risk of atherosclerotic cardiovascular events.
- Finally, treatment decisions should be based on patient and procedural characteristics, both of which vary widely in this heterogeneous population. Although limited compared to the coronary setting, randomized and observational evidence also exists in this setting and should be used in conjunction with clinical judgment and operator/center experience to guide decision making in HBR patients.
