Antithrombotic Therapy in High Bleeding Risk Part I: Percutaneous Cardiac Interventions (JACC Cardiovascular Interventions October 2024)-Article: Antithrombotic Therapy in High Bleeding Risk Part I: Percutaneous Cardiac Interventions

Article: Antithrombotic Therapy in High Bleeding Risk Part I: Percutaneous Cardiac Interventions

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The review discusses antithrombotic therapy in patients at high bleeding risk (HBR) undergoing percutaneous cardiac interventions. The balance between reducing thrombotic events and minimizing bleeding risk is crucial in these patients. Variability in patient responses necessitates personalized strategies. <br /><br />For those undergoing percutaneous coronary interventions (PCI) without the need for long-term oral anticoagulation (OAC), strategies such as dual antiplatelet therapy (DAPT) de-escalation have shown promise. This approach shortens the duration of DAPT or switches from more potent to less potent antiplatelet therapies, effectively reducing bleeding without significantly increasing ischemic events. For PCI patients who require OAC, evidence supports a move from triple antithrombotic therapy to dual therapy, combining a direct oral anticoagulant (DOAC) with a single antiplatelet agent, to reduce bleeding risks.<br /><br />In transcatheter aortic valve replacement (TAVR) patients, recent findings support the use of single antiplatelet therapy (SAPT) rather than DAPT to minimize bleeding without compromising efficacy. For patients needing OAC, monotherapy with a DOAC is generally favored, though the choice between DOACs and vitamin K antagonists remains contentious due to limited evidence.<br /><br />Left atrial appendage closure (LAAC) candidates frequently contain HBR individuals, often receiving combinations of antithrombotic therapy to prevent thrombi while mitigating bleeding risks. Common strategies include DAPT with clopidogrel and aspirin or reduced-dose DOAC regimens post-procedure. However, comprehensive guidelines for HBR patients in this category are less established.<br /><br />Mitral and tricuspid valve interventions predominantly rely on DAPT followed by SAPT for antithrombotic management, with ongoing research into the optimal strategies in these high-risk populations. Overall, the paper emphasizes the importance of tailored antithrombotic strategies in HBR patients to optimize the treatment benefits while minimizing bleeding risks.

Keywords

antithrombotic therapy

high bleeding risk

percutaneous cardiac interventions

dual antiplatelet therapy

direct oral anticoagulant

transcatheter aortic valve replacement

left atrial appendage closure

personalized strategies

bleeding risk management

tailored treatment