Abstract
Bleeding complications are common in patients treated with antiplatelet agents (APA), but their management relies on poor evidence. Therefore, practical guidelines and guidance documents are mainly based on expert opinion. The French Working Group on Perioperative Haemostasis provided proposals in 2018 to enhance clinical decisions regarding the management of APA-treated patients with a bleeding event. In light of these proposals, this review discusses the evidence and uncertainties of the management of patients with a bleeding event while on antiplatelet therapy. Platelet transfusion is the main option as an attempt to neutralise the effect of APA on primary haemostasis. Nevertheless, efficacy of platelet transfusion to mitigate clinical consequences of bleeding in patients treated with APA depends on the type of antiplatelet therapy, the time from the last intake, the mechanism (spontaneous versus traumatic) and site of bleeding and the criteria of efficacy (in vitro, in vivo). Specific antidotes for APA neutralisation are needed, especially for ticagrelor, but are not available yet. Despite the amount of information that platelet function tests are expected to give, little data support the clinical benefit of using such tests for the management of bleeding events in patients treated or potentially treated with APA.
Highlights
The four main oral antiplatelet agents (APA) have two different platelet molecular targets: aspirin inhibits the enzyme cyclooxygenase 1 and thromboxane A2 synthesis, while clopidogrel and prasugrel, and ticagrelor inhibit the adenosine diphosphate (ADP) pathway via the receptor P2Y12
Early platelet transfusion is recommended to treat haemorrhagic shock in attitudes based on high plasma/platelet/packed red blood cells ratios, independently of any chronic treatment interfering with haemostasis [19]
The GIHP, as well as others [1,18,50], proposes to use platelet function testing (PFT) to identify platelet dysfunctions, no matter the causes (APA or other), when they are suspected on a clinical basis, in teams trained in and accustomed to the use of the tests
Summary
The four main oral antiplatelet agents (APA) have two different platelet molecular targets: aspirin inhibits the enzyme cyclooxygenase 1 and thromboxane A2 synthesis, while clopidogrel and prasugrel (two thienopyridines), and ticagrelor inhibit the adenosine diphosphate (ADP) pathway via the receptor P2Y12. Whereas these drugs have demonstrated benefits regarding the prevention of arterial thrombosis and especially the recurrence of thrombotic events within appropriate indications, their use may result in bleeding complications.
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