Bleeding Complications in Patients Undergoing Percutaneous Coronary Intervention

Abstract

Percutaneous coronary intervention (PCI) is considered a relatively safe procedure associated with low rates of complications, but is inevitably associated with short and mid-to-long term increased bleeding risk. Besides the short term risk associated with the arterial access to perform PCI, enhanced bleeding risk persists for several months, given the need for antithrombotic therapy to prevent procedurerelated thrombotic complications as well as ischemic recurrences. Bleeding is a powerful harbinger of adverse outcomes. This awareness has fuelled intense research on bleeding reduction strategies, including new PCI devices and techniques as well as new medications and antithrombotic regimens. We here review the mechanisms and prevalence of bleeding in PCI patients, discuss the available evidence from a practical point of view, and explore future perspectives on how to treat and prevent bleeding complications in these patients.

De-escalation of antiplatelet therapy in acute coronary syndromes: Why, how and when?

“…Conversely, from the past decade, a particular attention has been paid to the most relevant adverse event associated with antithrombotic therapy: bleeding (9,14). Indeed, with the advent of second and third generation DES, the incidence of ST, including those occurring late and very late after PCI, has dramatically reduced, making prolonged and intense antithrombotic therapies no longer necessary for this purpose (13).…”

“…In particular, a more prolonged and intense antithrombotic therapy has been implemented in the attempt of preventing ST, a much feared complication of PCI associated with poor prognosis, whose incidence was relatively more frequent with the advent of first generation drug eluting stent (DES) ( 13 ). Conversely, from the past decade, a particular attention has been paid to the most relevant adverse event associated with antithrombotic therapy: bleeding ( 9 , 14 ). Indeed, with the advent of second and third generation DES, the incidence of ST, including those occurring late and very late after PCI, has dramatically reduced, making prolonged and intense antithrombotic therapies no longer necessary for this purpose ( 13 ).…”

“…Finally, it is now well known that the incidence of both local and ischemic events is highest during the first months after PCI and tends to decrease thereafter ( 1 ). On the contrary, the risk of bleeding, despite being relatively greater in the first days after PCI mainly because of the use of an arterial access site and periprocedural antithrombotic therapy, remains relatively stable over time ( 1 , 9 ). Therefore, a strategy of more intense antithrombotic therapy in the first 1–3 months after ACS/PCI followed by de-escalation of antiplatelet therapy thereafter has been implemented in several recent randomized controlled trials (RCTs), showing very promising results.…”

“…Nevertheless, because the use of this antiplatelet regimen is inevitably associated with increased bleeding risk and this risk may outweigh the benefit of a reduction of ischemic events in specific subgroup of patients, there has been a great interest in the personalization of antithrombotic therapy over the past years ( 8 ). This is further emphasized by the fact that a number of studies have demonstrated the adverse prognostic implications, including increased mortality, associated with a bleeding complication ( 9 ). Current guidelines, have proposed personalization of antiplatelet therapy according to patient’s bleeding and ischemic risk, with dedicated scores designed to predict and standardize such risks ( 6 , 7 ).…”

Gender-differences in antithrombotic therapy across the spectrum of ischemic heart disease: Time to tackle the Yentl syndrome?

“…Bleeding events have a significant downstream impact on mortality and morbidity outcomes among patients undergoing PCI ( 82 ). Sex-related differences have been observed also in terms of bleeding risk.…”