| Abstract [eng] |
Bleeding is a frequent and independently prognostic complication in patients with acute coronary syndromes (ACS) treated with dual antiplatelet therapy (DAPT), many of whom are managed in intensive cardiac care units (ICCUs). Despite evidence that higher-grade bleeding events carry mortality risks similar to, or greater than, those of recurrent ischaemic events, structured strategies for bleeding prevention and management remain not uniformly implemented in contemporary ACS and intensive cardiac care practice. The aim of this thesis was to critically review and synthesise the current evidence on bleeding management strategies in intensive cardiac care patients receiving antiplatelet therapy. The following objectives were pursued: (1) to review the epidemiology and clinical significance of bleeding complications in ACS patients on antiplatelet therapy; (2) to analyse current bleeding risk stratification tools and their role in guiding antiplatelet therapy decisions; (3) to evaluate evidence-based strategies for bleeding prevention, including DAPT de-escalation, duration abbreviation, and gastroprotection; and (4) to summarise the management of active bleeding in patients on antiplatelet therapy, including reversal approaches and special clinical scenarios. A narrative literature review was conducted using PubMed/MEDLINE, Cochrane Library, and Scopus. Sources published between 2016 and 2026 were prioritised, with seminal earlier works retained where appropriate. Primary evidence sources included the 2023 European Society of Cardiology (ESC) guidelines for ACS, the 2024 ESC chronic coronary syndromes guidelines, the 2025 American College of Cardiology / American Heart Association ACS guidelines, and major randomised controlled trials. Clinically actionable bleeding, defined as Bleeding Academic Research Consortium (BARC) type 2 or above, affects approximately 15–17% of ACS patients over 12 months, with nearly half of events occurring in the first 30 days [1]. Higher-grade BARC type 3 bleeding carries a mortality hazard comparable to or exceeding that of recurrent myocardial infarction, with intracranial haemorrhage (BARC type 3c) associated with the highest case-fatality burden [2,3]. Multiple validated risk stratification tools are available — including CRUSADE, PRECISE-DAPT, and the Academic Research Consortium for High Bleeding Risk (ARC-HBR) criteria — but real-world concordance between instruments is limited, with approximately 22% of patients classified discordantly by PRECISE-DAPT and ARC-HBR [4]. DAPT de-escalation strategies, primarily involving switching from potent P2Y12 inhibition to clopidogrel, reduced both bleeding (hazard ratio 0.70) and ischaemic events (hazard ratio 0.76) in an individual patient data meta-analysis of 10,133 patients [5]. Other de-escalation approaches, including aspirin withdrawal, prasugrel dose reduction, and DAPT abbreviation, are supported by additional randomised trials. Transradial arterial access and proton pump inhibitor co-prescription carry Class I ESC recommendations in appropriate ACS patient groups and reduce access-site and gastrointestinal bleeding, respectively [6]. Management of active bleeding relies on agent-specific strategies: platelet transfusion appears most effective for aspirin and least effective for ticagrelor; desmopressin and tranexamic acid serve as adjuncts; and bentracimab, a specific ticagrelor reversal agent, has shown rapid restoration of platelet function in early-phase studies and demonstrated effective haemostasis in 94.3% of patients in a Phase 3 trial per conference-reported data (peer-reviewed publication pending), but remains investigational [7,8]. |
