High bleeding risk patients undergoing percutaneous coronary intervention
- J Dawn Abbott, MD, FACC
J Dawn Abbott, MD, FACC
- Associate Professor of Medicine
- Brown Medical School
- Section Editors
- Donald Cutlip, MD
Donald Cutlip, MD
- Section Editor — Interventional Cardiology
- Professor of Medicine
- Harvard Medical School
- Beth Israel Deaconess Medical Center
- Stephan Windecker, MD
Stephan Windecker, MD
- Section Editor — Coronary Heart Disease
- Professor of Medicine
- Department of Cardiology
- Bern University Hospital
Percutaneous coronary intervention (PCI) with placement of an intracoronary stent requires treatment with dual antiplatelet therapy (DAPT) for some period of time, which is as short as one month or as long as up to three years. (See "Long-term antiplatelet therapy after coronary artery stenting in stable patients".)
Such therapy improves outcomes of cardiac mortality and myocardial infarction (MI). Some of the improvement is attributable to a reduction in the incidence of stent thrombosis, a complication often associated with MI and death. However, DAPT is associated with an increased risk of major bleeding. For patients undergoing PCI who are identified as being at high risk of bleeding, the optimal management strategy is not known. This topic will discuss this issue in detail.
Other relevant topics include:
- Baber U, Mehran R, Giustino G, et al. Coronary Thrombosis and Major Bleeding After PCI With Drug-Eluting Stents: Risk Scores From PARIS. J Am Coll Cardiol 2016; 67:2224.
- Ducrocq G, Wallace JS, Baron G, et al. Risk score to predict serious bleeding in stable outpatients with or at risk of atherothrombosis. Eur Heart J 2010; 31:1257.
- Berger PB, Bhatt DL, Fuster V, et al. Bleeding complications with dual antiplatelet therapy among patients with stable vascular disease or risk factors for vascular disease: results from the Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance (CHARISMA) trial. Circulation 2010; 121:2575.
- Valle JA, Shetterly S, Maddox TM, et al. Postdischarge Bleeding After Percutaneous Coronary Intervention and Subsequent Mortality and Myocardial Infarction: Insights From the HMO Research Network-Stent Registry. Circ Cardiovasc Interv 2016; 9.
- Généreux P, Giustino G, Witzenbichler B, et al. Incidence, Predictors, and Impact of Post-Discharge Bleeding After Percutaneous Coronary Intervention. J Am Coll Cardiol 2015; 66:1036.
- Cutlip DE, Kereiakes DJ, Mauri L, et al. Thrombotic complications associated with early and late nonadherence to dual antiplatelet therapy. JACC Cardiovasc Interv 2015; 8:404.
- Ko DT, Yun L, Wijeysundera HC, et al. Incidence, predictors, and prognostic implications of hospitalization for late bleeding after percutaneous coronary intervention for patients older than 65 years. Circ Cardiovasc Interv 2010; 3:140.
- Kazi DS, Leong TK, Chang TI, et al. Association of spontaneous bleeding and myocardial infarction with long-term mortality after percutaneous coronary intervention. J Am Coll Cardiol 2015; 65:1411.
- Brener SJ, Kirtane AJ, Stuckey TD, et al. The Impact of Timing of Ischemic and Hemorrhagic Events on Mortality After Percutaneous Coronary Intervention: The ADAPT-DES Study. JACC Cardiovasc Interv 2016; 9:1450.
- Ariotti S, Adamo M, Costa F, et al. Is Bare-Metal Stent Implantation Still Justifiable in High Bleeding Risk Patients Undergoing Percutaneous Coronary Intervention?: A Pre-Specified Analysis From the ZEUS Trial. JACC Cardiovasc Interv 2016; 9:426.
- Urban P, Meredith IT, Abizaid A, et al. Polymer-free Drug-Coated Coronary Stents in Patients at High Bleeding Risk. N Engl J Med 2015; 373:2038.
- Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2016; 68:1082.
- Roffi M, Patrono C, Collet JP, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J 2016; 37:267.
- DEFINITION OF HIGH BLEEDING RISK
- ASSESSING BLEEDING RISK
- INCIDENCE OF BLEEDING AFTER PCI
- PROGNOSIS AFTER BLEEDING
- COMPARING BLEEDING AND ISCHEMIC RISK
- BMS VERSUS DES
- MANAGEMENT OF BLEEDING
- OUR APPROACH
- Choice of stent
- P2Y12 receptor blocker
- - Agent
- - Duration
- Timing of PCI
- RECOMMENDATIONS OF OTHERS
- SUMMARY AND RECOMMENDATIONS