Antiplatelet agents in uncertain clinical scenarios-a bleeding nightmare

Ischemic and Bleeding Events in PENDULUM Patients With High Bleeding Risk and High Platelet Reactivity

BACKGROUND

The balance between thrombotic and bleeding risk is of great concern in high bleeding risk (HBR) patients. This study evaluated the relationship between perioperative antiplatelet reactivity and thrombotic and bleeding events in patients at HBR undergoing percutaneous coronary intervention (PCI).Methods and Results:In this post hoc analysis of the PENDULUM (Platelet rEactivity in patieNts with DrUg eLUting stent and balancing risk of bleeding and ischeMic event) registry, patients undergoing PCI were categorized as HBR or non-HBR, and stratified as having high platelet reactivity (HPR; P2Y₁₂reaction unit [PRU] >208) or non-HPR (PRU ≤208). Cumulative incidences of cardiovascular and cerebrovascular events (Journal of the American College of Cardiologyexpert definitions) and bleeding events (Bleeding Academic Research Consortium criteria) were assessed 12 months after index PCI. The incidence of ischemic and bleeding events was ~3-fold higher in HBR vs. non-HBR patients. Thrombotic/ischemic events were significantly more common in the HPR subgroup in HBR patients (hazard ratio [HR]: 1.59; 95% confidence interval [CI]: 1.11-2.28; P=0.012), but there was no difference in non-HBR patients. After adjustment for covariates, HPR in HBR patients remained an independent factor for thrombotic and ischemic events (HR: 1.69; 95% CI: 1.13-2.54; P=0.011), but not for bleeding events (HR: 1.56; 95% CI: 0.78-3.11; P=0.210).

CONCLUSIONS

Maintaining adequate PRU levels during PCI is an important factor in improving clinical outcomes, especially for HBR patients.

From Coronaries to Cirrhosis: The Role of Percutaneous Coronary Intervention and Dual Antiplatelet Therapy in End-Stage Liver Disease

Drug-eluting stents (DES) have superior efficacy compared with bare metal stents (BMS) for treatment of coronary artery lesions. However, BMS continue to play an important role in percutaneous coronary intervention for patients who are at a high bleeding risk, because they require a shorter duration of dual antiplatelet therapy. However, new developments in DES and understanding of the optimal time required for dual antiplatelet therapy after percutaneous coronary intervention may further limit the use of BMS. Furthermore, the use of dual antiplatelet therapy is complicated in patients with cirrhosis, who may have coagulopathy. In this article, we present the case of a patient with cirrhosis and end-stage chronic liver disease with coronary artery disease and a proximal left anterior descending stenosis who received a DES and had multiple episodes of gastrointestinal bleeding. We review the literature addressing DES and BMS in patients at high risk of bleeding. We also review the optimal duration of dual antiplatelet therapy.

Dual Versus Triple Therapy in Patients with Acute Coronary Syndrome and an Anticoagulation Indication: A Systematic Review with Meta-Analysis and Trial-Sequential Analysis

Choosing an antithrombotic regime in patients with acute coronary syndrome (ACS) and a concomitant indication for anticoagulation is a challenge commonly encountered by clinicians. Our aim in this article is to evaluate the safety and efficacy of triple antithrombotic therapy (TT, anticoagulant plus dual antiplatelet) versus dual antithrombotic therapy [dual therapy (DT), anticoagulant plus single antiplatelet] in patients with ACS. We included all randomized trials comparing the outcomes of single versus dual antiplatelet therapy in patients with ACS on anticoagulants. The primary outcome was major adverse cardiac events (MACE). Other outcomes studied were all-cause mortality, cardiovascular mortality, myocardial infarction (MI), stroke, stent thrombosis (ST), and major bleeding. The Mantel-Haenszel risk ratio (RR) random-effects model was used to summarize data. Six studies, with a total of 11,437 patients, met our selection criteria. With a follow-up duration of 9-14 months, there was no significant difference between DT and TT in terms of MACE [RR 0.96; 95% confidence interval (CI), 0.79-1.17], all-cause mortality (RR 1.00; 95% CI, 0.77-1.29), cardiovascular mortality (RR 1.03; 95% CI, 0.79-1.34), MI (RR 1.14; 95% CI, 0.90-1.45), stroke (RR 0.83; 95% CI, 0.56-1.23), and ST (RR 1.32; 95% CI, 0.87-2.01). Compared with TT, DT was associated with significant reductions in major bleeding 4.1% versus 6.5% (RR 0.61; 95% CI, 0.45-0.81; number needed to treat = 42), clinically significant bleeding 10.5% versus 16.4% (RR 0.62; 95% CI, 0.48-0.80) and intracranial hemorrhage 0.4% versus 0.8% (RR 0.43; 95% CI, 0.24-0.77). In patients on anticoagulant therapy, the strategy of single antiplatelet therapy (DT) confers a benefit of less major bleeding with no difference in MACE, all-cause mortality, cardiovascular mortality, MI, stroke, and ST.

Anticoagulant Use and Bleeding Risk in Central European Patients with Idiopathic Pulmonary Fibrosis (IPF) Treated with Antifibrotic Therapy: Real-World Data from EMPIRE

INTRODUCTION

Nintedanib, a tyrosine kinase receptor inhibitor, may be associated with increased bleeding risk. Thus, patients with an inherited predisposition to bleeding, or those receiving therapeutic doses of anticoagulants or high-dose antiplatelet therapy, have been excluded from clinical trials of nintedanib in idiopathic pulmonary fibrosis (IPF).

OBJECTIVE

Our objective was to examine real-world bleeding events in patients with IPF treated with antifibrotics, including those receiving anticoagulants and/or antiplatelet therapy.

METHODS

The European MultiPartner IPF Registry (EMPIRE) enrolled 2794 patients with IPF: group A (1828: no anticoagulant or antiplatelet treatment), group B (227: anticoagulant treatment), group C (659: antiplatelet treatment), and group D (80: anticoagulant and antiplatelet treatment). Overall, 673 (24.1%) received nintedanib and 933 (33.4%) received pirfenidone. Bleeding events and their relationship to antifibrotic and anticoagulation treatment were characterized.

RESULTS

Group A patients, versus those in groups B, C, and D, were typically younger and generally had the lowest comorbidity rates. A higher proportion of patients in groups A and C, versus group B, received nintedanib. Pirfenidone, most common in group D, was more evenly balanced across groups. In patients with reported bleeding events, seven of eight received nintedanib (groups A, C, and D). Bleeding incidence was 3.0, 0, 1.3, and 18.1 per 10,000 patient-years (groups A, B, C, and D, respectively).

CONCLUSION

Real-world data from EMPIRE showed that patients on anticoagulant medications received nintedanib less frequently, perhaps based on its mechanism of action. Overall, bleeding incidence was low (0.29%: nintedanib 0.25%; pirfenidone 0.04%) and irrespective of anticoagulant or antiplatelet therapy received (P = 0.072).

Bleeding risk assessment in elderly patients with acute coronary syndrome

Nowadays, elderly people represent a growing population segment with a well known increased risk of both ischemic and bleeding events. Current acute coronary syndrome guidelines, strongly recommend dual antiplatelet therapy (DAPT) with few specific references for aged patients due to lack of evidence. Patients aged ≥ 75 years are misrepresented in the classic derivation trials cohorts. Strategies to reduce the bleeding risk in this group of patients are urgently needed for the daily clinical practice. Identify the specific age related bleeding risk factors and the importance of an integral geriatric assessment remains challenging. Some of the available in-hospital and out-hospital bleeding risk scores have shown a lower to moderate predictive ability in older patients and no specific tools are developed in elderly population. The importance of an appropriate vascular access choice, type and duration of antiplatelet drugs is crucial to reduce the bleeding risk. Increase radial approaches and short DAPT duration leads to reduce hemorrhages. One interesting subgroup of patients is those who need chronic anticoagulation therapy after percutaneous coronary intervention, due to their very high risk of bleeding. New alternatives as dual therapy with oral anticoagulation and only one antiplatlet drug should be considered. In current review, we evaluate the available evidence about bleeding risk in elderly.