Antithrombotic Therapy in Patients at High Bleeding Risk: Key Points
The following are key points to remember from a state-of-the-art review on antithrombotic therapy in patients at high bleeding risk (HBR) from the Working Group of Thrombosis of the Italian Society of Cardiology:
- Antithrombotic therapy after percutaneous cardiac interventions is key for the prevention of thrombotic events but is inevitably associated with increased bleeding, proportional to the number, duration, and potency of the antithrombotic agents used.
- Bleeding complications have important clinical implications, which in some cases may potentially outweigh the expected benefit of reducing thrombotic events.
- Because the response to antithrombotic agents varies widely among patients, there has been a relentless effort toward the identification of patients at HBR, in whom modulation of antithrombotic therapy may be needed to optimize the balance between safety and efficacy.
- Among patients undergoing percutaneous cardiac interventions, recent advances in technology have allowed for strategies of de-escalation to reduce bleeding without compromising efficacy, and HBR patients are expected to benefit the most from such approaches.
- Current guidelines do not extensively expand upon the topic of de-escalation strategies of antithrombotic therapy in HBR patients. This document provides practical recommendations on optimal antithrombotic therapy in HBR patients undergoing various cardiac percutaneous interventions.
- For patients undergoing coronary stenting who do not have an indication for oral anticoagulation (OAC): de-escalation and short dual antiplatelet therapy (DAPT) strategies should be considered; for those who have an indication for OAC: evidence suggests up to 1 week of triple antithrombotic therapy followed by 3-6 months of double antithrombotic therapy using clopidogrel and a direct oral anticoagulant (DOAC) as the default strategy.
- For patients undergoing aortic valve replacement (AVR) who do not have an indication for OAC: single antiplatelet therapy is considered to be safer and similarly effective to DAPT after transcatheter AVR; for those who have an indication for OAC: OAC monotherapy should be the first-line therapy, but whether DOACs or vitamin K antagonists should be preferred is less defined.
- For patients undergoing left atrial appendage occlusion who do not have an indication for OAC: clopidogrel-based DAPT for 1 month followed by aspirin alone, alternatively aspirin alone may be used; for those who have an indication for OAC: OAC alone is recommended; aspirin is reserved for patients with a contraindication to OAC.
- For patients undergoing mitral or tricuspid interventions who do not have an indication for OAC: clopidogrel-based DAPT for 1 month followed by aspirin alone, alternatively aspirin alone may be used; for those who have an indication for OAC: OAC alone is recommended; aspirin is reserved for patients with a contraindication to OAC.
- Prompt identification of HBR status and use of tailored antithrombotic treatment regimens is of utmost importance to optimize the balance between bleeding and thrombotic risk in these patients. In addition, dedicated trials are warranted to best define the optimal antithrombotic strategy in HBR patients undergoing cardiac percutaneous interventions for coronary and structural heart diseases.
