Bleeding in acute coronary syndrome: from definitions, incidence, and prognosis to prevention and management

ABSTRACT

Introduction

In patients with acute coronary syndrome (ACS), the ischemic benefit of antithrombotic treatment is counterbalanced by the risk of bleeding. The recognition that bleeding events have prognostic implications (i.e. mortality) similar to recurrent ischemic events led to the development of treatment regimens aimed at balancing both ischemic and bleeding risks.

Areas covered

This review aims at describing definitions, incidence, and prognosis related to bleeding events in ACS patients as well as bleeding-avoidance strategies for their prevention and management of bleeding complications.

Expert opinion

Management of ACS patients has witnessed remarkable progress after the shift in focusing on the trade-off between ischemia and bleeding. Efforts in standardizing bleeding definitions will allow for better defining the prognostic impact of different types of bleeding events and enable to identify the high-bleeding risk patient. Such efforts will allow to balance the trade-off between the thrombotic and bleeding risk of the individual patient translating into better downward diagnostic and therapeutic decision-making. Novel strategies aiming at maximizing the safety and efficacy of antithrombotic regimens as well as the development of novel antithrombotic drugs and reversal agents and technological advances will allow for optimization of bleeding-avoidance strategies and management of bleeding complications.

KEYWORDS:

• Acute coronary syndromes
• bleeding
• DAPT de-escalation
• high bleeding risk patients
• bleeding management

Article highlights

• Patients with ACS requiring DAPT experience bleeding events more often than previously thought, and bleeding may be as harmful as subsequent ischemia.

• Different risk-stratification tools may be used at admission and at the time of PCI or at discharge to predict the risk of subsequent bleeding and ischemia, allowing more precise patient management at different moments of the diagnostic and treatment pathway.

• DAPT de-escalation strategies include different regimens aiming to be more intense in the first months after ACS and less intense subsequently, in order to account for the evolution of ischemic and bleeding risks over time.

• Even if diagnostic and therapeutic pathways are chosen after proper risk stratification, bleeding may still arise. In such cases, DAPT discontinuation and use of reversal agents should be selected on the basis of the time from the latest stent implantation.

• Current guidelines highlight the importance of balancing between bleeding and thrombotic risks in the management of patients with ACS, both in the short- and long-term management, supporting the use of tools for risk stratification to guide diagnostic and treatment decision pathways.

• Several trials are ongoing to further evaluate risk-stratification tools, DAPT de-escalation strategies and antiplatelet and anticoagulant reversal agents.

Declaration of interests

DJ Angiolillo declares that he has received consulting fees or honoraria from Abbott, Amgen, AstraZeneca, Bayer, Biosensors, Boehringer Ingelheim, Bristol-Myers Squibb, Chiesi, Daiichi-Sankyo, Eli Lilly, Haemonetics, Janssen, Merck, Novartis, PhaseBio, PLx Pharma, Pfizer, Sanofi and Vectura; DJ Angiolillo also declares that his institution has received research grants from Amgen, AstraZeneca, Bayer, Biosensors, CeloNova, CSL Behring, Daiichi-Sankyo, Eisai, Eli Lilly, Gilead, Idorsia, Janssen, Matsutani Chemical Industry Co., Merck, Novartis, and the Scott R. MacKenzie Foundation. D Capodanno reports advisory board or speaker’s honoraria from Chiesi, Novo Nordisk, Sanofi, Terumo. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Author contribution statement

DJA conceived the paper.

CL, DC, and DJA independently assessed studies and collected data for this review.

All authors contributed to drafting the manuscript, revised and approved the final version of the manuscript.

DJA had final responsibility for the decision to submit for publication.

Additional information

Funding

This paper was not funded.