Temporal Trends in in-Hospital Bleeding and Transfusion in a Contemporary Canadian ST-Elevation Myocardial Infarction Patient Population

Tailoring Antithrombotic Regimens for Percutaneous Coronary Intervention Patients with High Bleeding and Ischemic Risk (TAILOR-BIRISK): Individualized Management and Genotype-Guided De-escalation

Percutaneous coronary intervention (PCI) is a widely used reperfusion strategy for coronary artery disease, with millions of procedures performed annually. Attention has recently been drawn to a unique population, known as "bi-risk" patients, who have high ischemic and high bleeding risks and undergo PCI. However, there is currently no established definition or optimal antithrombotic therapy for this group. Genotype-guided antithrombotic therapy, which uses cytochrome P450 (CYP) 2C19 gene testing, may offer a more personalized and precise approach. Nevertheless, recent research has shown that routine genetic testing to guide treatment in the PCI population does not improve patient outcomes, preventing it from being routinely recommended in guidelines. This review proposes, for the first time, the definition of the bi-risk population and the concept of TAILOR-BIRISK for their treatment strategies. TAILOR-BIRISK emphasizes de-escalating antithrombotic treatment and suggests that a short course of dual antiplatelet therapy (DAPT) followed by monotherapy by either clopidogrel or ticagrelor 60 mg BID (BID, twice daily) could be a reasonable option for this population. Additionally, the use of CYP2C19 gene testing to guide P2Y 12 inhibitor selection can help better individualize and customize the antithrombotic regimen. However, more large-sample randomized control studies should be conducted to further explore the optimal antithrombotic strategy for the bi-risk population.

Bleeding avoidance strategies in percutaneous coronary intervention

For many years, bleeding has been perceived as an unavoidable consequence of strategies aimed at reducing thrombotic complications in patients undergoing percutaneous coronary intervention (PCI). However, the paradigm has now shifted towards bleeding being recognized as a prognostically unfavourable event to the same extent as having a new or recurrent ischaemic or thrombotic complication. As such, in parallel with progress in device and drug development for PCI, there is clinical interest in developing strategies that maximize not only the efficacy but also the safety (for example, by minimizing bleeding) of any antithrombotic treatment or procedural aspect before, during or after PCI. In this Review, we discuss contemporary data and aspects of bleeding avoidance strategies in PCI, including risk stratification, timing of revascularization, pretreatment with antiplatelet agents, selection of vascular access, choice of coronary stents and antithrombotic treatment regimens.