Bleeding after antiplatelet therapy for the treatment of acute coronary syndromes: a review of the evidence and evolving paradigms

ABSTRACT

Introduction: Potent platelet inhibition reduces the risk of thrombotic complications including myocardial infarction and death in patients with acute coronary syndrome (ACS). Targeting different pathways involved in thrombotic processes have synergistic effects and more effectively counteract thrombosis both in the acute and long-term following an ACS. Unavoidably, more potent platelet inhibition increases the risk of bleeding. In light of the adverse prognostic implications associated with bleeding, including increased mortality, safety aspects with antiplatelet therapy have gained increased importance.

Areas covered: This review aims at describing the safety of different antiplatelet agents, particularly with regards to the risk of bleeding complications, used in the management of ACS patients. New bleeding reduction strategies to enhance the safety of antiplatelet therapy are also reviewed.

Expert opinion: The final goal of a well-structured antiplatelet treatment strategy is that of tackling the spectrum of ischemic risk without compromising patient safety. A simple mnemonic rule for guiding therapeutic decisions in this complex clinical scenario can be summarized with the acronym ‘ABC’, meaning the sequential process of assessing, balancing and customizing treatment strategies in individual patients on the tradeoff between bleeding and ischemic risk. This approach is recommended for maximizing the ischemic benefits, while preserving safety, with the use of antiplatelet therapy.

KEYWORDS:

• Antiplatelet therapy
• bleeding
• risk stratification
• secondary cardiovascular prevention

Article highlights

• Counteracting platelet-triggered thrombosis by using potent platelet inhibitors to limit the amount of myocardium put in jeopardy and to prevent future events is a fundamental paradigm in the therapeutic management of acute coronary syndrome (ACS) patients.

• Although antiplatelet therapies reduce thrombotic complications in ACS patients, this comes at the expense of increased bleeding.

• Bleeding represents one of the most relevant safety aspects with antiplatelet therapy since it has been associated with worse prognosis, including increased mortality.

• A variety of antiplatelet agents can be employed for the therapeutic management of ACS patients. Different therapeutic combinations, either in terms of drug choices and/or duration of treatment, have paved the way for the individualization of antiplatelet treatment strategies.

• New strategies to minimize the risk of bleeding in patients requiring antiplatelet treatment are under investigation.

This box summarizes key points contained in the article.

Declaration of interest

DJ Angiolillo declares that he has received consulting fees or honoraria from Amgen, Aralez, AstraZeneca, Bayer, Biosensors, Boehringer Ingelheim, Bristol-Myers Squibb, Chiesi, Daiichi-Sankyo, Eli Lilly, Haemonetics, Janssen, Merck, PhaseBio, PLx Pharma, Pfizer, Sanofi and The Medicines Company, and has received payments for participation in review activities from CeloNova and St Jude Medical. 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, Osprey Medical, and Renal Guard Solutions. D Capodanno discloses the following relationships: speakers’ honoraria from Bayer, AstraZeneca, Daiichi Sankyo, Pfizer and Boehringer Ingelheim, and consulting fees from Abbott Vascular, Bayer and Daiichi Sankyo. S James reports institutional research grants from AstraZeneca, Bayer, Jansen, The Medicines Company, Abbot Vascular and Boston Scientific, as well as honoraria from AstraZeneca, Bayer, and Medtronic. 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.

Additional information

Funding

This paper was not funded.