Abstract
Inhibition of platelet function by means of dual antiplatelet therapy (DAPT) is the cornerstone of treatment of acute coronary syndrome (ACS). While preventing ischemic recurrences, inhibition of platelet function is clearly associated with an increased bleeding risk, a feared complication that may lead to significant morbidity and mortality. Since bleeding risk management is intrinsically associated with therapeutic adjustments undertaken during the whole clinical history of patients with acute coronary syndrome, single decisions taken from the very first day to years of follow-up might be decisive. This review aims at providing a clinically oriented, patient-tailored approach in reducing the risk and manage bleeding complications in ACS patients treated with DAPT. The steps in clinical decision making from the day of ACS to follow-up are analyzed. New treatment strategies to enhance the safety of DAPT are also described.
Highlights
Inhibition of platelet function following acute coronary syndrome (ACS) using dual antiplatelet therapy (DAPT) is aimed at preventing the occurrence of short- and long-term thrombotic complications.In the first weeks after percutaneous revascularization DAPT reduces the risk of stent thrombosis, a potentially fatal event occurring as a result of inflammation and endothelial damage associated with mechanical insult during percutaneous coronary interventions (PCI), the so-called “stent protective effect” [1,2]
Similar results were obtained in the DAPT trial [4], in which continuation of DAPT with clopidogrel or prasugrel for more than 12 months after coronary stenting showed a reduction in non-fatal ischemic events, but an increase in major bleeding compared to single antiplatelet therapy (SAPT) with aspirin and placebo
A recent retrospective study of pooled data of randomized controlled trials (RCT) showed that patients who were treated with complex PCI had a higher risk of ischemic events but benefitted from long-term DAPT only if HBR features were not present
Summary
Inhibition of platelet function following acute coronary syndrome (ACS) using dual antiplatelet therapy (DAPT) is aimed at preventing the occurrence of short- and long-term thrombotic complications. Even less severe bleeding might increase mortality via indirect mechanisms such as unplanned hospitalization, need for urgent procedures, and DAPT discontinuation [14]. The need for transfusions of red blood cells, by increasing inflammation and apoptosis, is a possible link between bleeding and mortality [27]. Bleeding is a major driver of unplanned DAPT discontinuation, which increases the risk of ischemic recurrences [28]. Besides DAPT, other key cardioprotective medications like beta-blockers, Renin–Angiotensin–Aldosterone System (RAAS) blockers or statins are often discontinued after bleeding, further increasing the risk for recurrent events [29]. Reflecting the importance of the prognostic association between bleeding and mortality, current guideline recommendations advocate for bleeding avoidance strategies starting from the time of revascularization and continuing in the long-term after the acute clinical presentation [7]
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