Decoding Bleeding Risks and Survival in Patients Undergoing Percutaneous Coronary Intervention on Antiplatelet Therapy (JACC Asia September 2025)-Article: Decoding Bleeding Risks and Survival in Patients Undergoing Percutaneous Coronary Intervention on Antiplatelet Therapy

Article: Decoding Bleeding Risks and Survival in Patients Undergoing Percutaneous Coronary Intervention on Antiplatelet Therapy

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This comprehensive 2025 review in JACC Asia addresses bleeding risks and survival outcomes in patients with coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI) while on antiplatelet therapy. Dual antiplatelet therapy (DAPT) is standard care post-PCI but substantially increases bleeding risk, which ranges between 1%-10% in trials and 2.8%-11% in real-world studies. The Academic Research Consortium for High Bleeding Risk (ARC-HBR) criteria classify about half of PCI patients as high bleeding risk (HBR), who face significantly higher bleeding rates and mortality.<br /><br />The article highlights evolving bleeding definitions, emphasizing the Bleeding Academic Research Consortium (BARC) standardized scale for consistent assessment. It details bleeding risk stratification tools—such as ARC-HBR, PRECISE-DAPT, PARIS, and scores tailored for East Asian populations (e.g., J-HBR, Asian DAPT, CREDO-Kyoto, KAMIR-NIH)—which guide personalized therapy to balance thrombotic prevention with bleeding risk mitigation.<br /><br />Distinct "East Asian paradox" is discussed: East Asians exhibit higher bleeding but lower ischemic risks compared to Western populations, linked partly to genetic differences affecting clopidogrel metabolism. This necessitates customized antiplatelet strategies in these populations.<br /><br />The review underscores that bleeding events strongly increase mortality risk post-PCI, via mechanisms like disrupted hemostasis, hypercoagulability, and mandatory antithrombotic medication discontinuation. Minor or "nuisance" bleeding, though often underestimated, can lead to therapy nonadherence and adverse outcomes.<br /><br />Patients with overlapping high ischemic and bleeding risks ("bi-risk") represent a clinical challenge. Recent trials (OPT-BIRISK, HOST-EXAM) support clopidogrel monotherapy after initial DAPT to reduce bleeding without raising ischemic events in these patients.<br /><br />Overall, the paper advocates a shift towards individualized, bleeding-risk–first management in antiplatelet therapy post-PCI. It calls for tailored approaches based on validated risk scores, population-specific factors, and balancing ischemic versus bleeding risks to optimize survival and outcomes for CAD patients globally, especially in East Asian cohorts.

Keywords

coronary artery disease

percutaneous coronary intervention

dual antiplatelet therapy

bleeding risk

Academic Research Consortium for High Bleeding Risk

Bleeding Academic Research Consortium scale

East Asian paradox

clopidogrel metabolism

bi-risk patients

personalized antiplatelet therapy