What is the recommended Dual Antiplatelet Therapy (DAPT) regimen for patients at high risk of bleeding post-stenting?

Management of DAPT in Patients with High Bleeding Risk Post-Stenting

For patients at high risk of bleeding after coronary stenting, dual antiplatelet therapy (DAPT) should be limited to 1-3 months, followed by single antiplatelet therapy, with clopidogrel as the preferred P2Y12 inhibitor. 1

Defining High Bleeding Risk Post-Stenting

High bleeding risk after coronary stenting is defined by the Academic Research Consortium criteria 1:

Major Criteria (any one):

• Age ≥75 years
• Anticipated use of long-term oral anticoagulation
• Severe or end-stage chronic kidney disease (eGFR <30 mL/min)
• Hemoglobin <11 g/dL
• Spontaneous bleeding requiring hospitalization or transfusion in past 6 months
• Chronic bleeding diathesis
• Active malignancy within past 12 months
• Previous spontaneous intracranial hemorrhage
• Brain arteriovenous malformation
• Nondeferrable major surgery while on DAPT

Minor Criteria (any two):

• Age 65-74 years
• Long-term use of oral NSAIDs or steroids
• Moderate CKD (eGFR 30-59 mL/min)
• Hemoglobin 11-12.9 g/dL for men and 11-11.9 g/dL for women
• Spontaneous bleeding requiring hospitalization in past 12 months
• Moderate or severe thrombocytopenia (<100×10⁹/L)
• Liver cirrhosis with portal hypertension
• Any ischemic stroke
• Previous traumatic intracranial hemorrhage within past 12 months
• Recent major surgery or trauma within 30 days before PCI

DAPT Regimen for High Bleeding Risk Patients

Duration:

• For high bleeding risk patients: Limit DAPT to 1-3 months 1
• After stent implantation with high bleeding risk (e.g., PRECISE-DAPT score ≥25 or ARC-HBR criteria met), discontinuation of P2Y12 receptor inhibitor therapy after 3 months is recommended 1
• In very high bleeding risk cases, consider even shorter DAPT duration (1 month) 1

Choice of Antiplatelet Agents:

1. Aspirin: 75-100 mg daily (lower doses associated with fewer bleeding complications) 1
2. P2Y12 inhibitor: Clopidogrel 75 mg daily is the preferred agent for high bleeding risk patients 1, 2
   • Avoid more potent P2Y12 inhibitors (prasugrel, ticagrelor) in high bleeding risk patients due to increased bleeding risk 3

Special Considerations

Patients Requiring Oral Anticoagulation:

• For patients requiring both DAPT and oral anticoagulation, consider:
  • Early cessation (≤1 week) of aspirin and continuation of dual therapy with an OAC and clopidogrel 1
  • Triple therapy (aspirin + clopidogrel + OAC) should be limited to ≤1 month 1
  • For high bleeding risk patients, consider triple therapy for 1 month, then dual therapy (OAC + clopidogrel) for up to 12 months 2

Bleeding Risk Reduction Strategies:

• Use proton pump inhibitors for gastrointestinal protection 1, 2
• Prefer radial over femoral access for any coronary procedures 1, 2
• If using warfarin, maintain INR in the lower therapeutic range 2
• Consider de-escalation of DAPT (switching from more potent P2Y12 inhibitors to clopidogrel) 1

Management During Bleeding Events:

• For minor bleeding: Consider reducing triple therapy to dual therapy (OAC + clopidogrel) 2
• For major bleeding: Temporarily withhold antiplatelet agents if necessary, consider reversal agents, and resume therapy after adequate hemostasis 2

Recent Evidence and Evolving Approaches

Recent meta-analyses show that short DAPT (≤3 months) followed by P2Y12 inhibitor monotherapy significantly reduces net adverse clinical events and major bleeding compared to 12-month DAPT, without increasing ischemic events 4.

The PRECISE-DAPT score (age, creatinine clearance, hemoglobin, white blood cell count, and previous spontaneous bleeding) can help predict out-of-hospital bleeding risk during DAPT, with scores ≥25 indicating high bleeding risk 5.

Common Pitfalls to Avoid

1. Never discontinue both antiplatelet agents simultaneously in patients with coronary stents due to high risk of stent thrombosis 1
2. Avoid using prasugrel in patients ≥75 years due to increased risk of fatal and intracranial bleeding 3
3. Don't automatically use 12-month DAPT for all patients - duration should be tailored based on bleeding risk 1
4. Don't use vitamin K for treatment of bleeding associated with direct oral anticoagulants (DOACs) 1

By carefully assessing bleeding risk and implementing appropriate DAPT strategies, clinicians can minimize bleeding complications while maintaining adequate protection against thrombotic events in post-stenting patients.