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  • Review Article
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Bleeding avoidance strategies in percutaneous coronary intervention

Nature Reviews Cardiology volume 19, pages 117–132 (2022)Cite this article

Subjects

Abstract

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.

Key points

  • For years, concerns about thrombosis and recurrent ischaemia in patients undergoing percutaneous coronary intervention (PCI) have prevailed, prompting the use of potent antithrombotic strategies and long durations of dual antiplatelet therapy.

  • Remarkable improvements in the way in which PCI is performed have led to a new interest in investigating strategies that target bleeding, especially in patients at higher risk of bleeding.

  • Patients at high risk of bleeding should be promptly identified to define appropriate bleeding prevention strategies.

  • Bleeding avoidance strategies include actions targeted at minimizing the risk of bleeding before, during and after PCI.

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Fig. 1: Bleeding avoidance strategies before, during and after PCI.
Fig. 2: Factors associated with an increased risk of bleeding after PCI.
Fig. 3: Safe zone for femoral artery access for percutaneous coronary intervention.
Fig. 4: Trials of short DAPT after PCI in patients at high risk of bleeding.
Fig. 5: Trials of short DAPT after PCI in all-comer patients regardless of the risk of bleeding.

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Authors and Affiliations

  1. Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico “G. Rodolico-San Marco”, University of Catania, Catania, Italy

    Davide Capodanno

  2. Department of Medicine, Brigham and Women’s Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA, USA

    Deepak L. Bhatt

  3. Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA

    C. Michael Gibson

  4. Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University Hospital, Uppsala, Sweden

    Stefan James

  5. Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan

    Takeshi Kimura

  6. Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA

    Roxana Mehran

  7. The Duke Clinical Research Institute, Durham, NC, USA

    Sunil V. Rao

  8. Département Hospitalo-Universitaire FIRE, AP-HP, Hôpital Bichat, Paris, France

    Philippe Gabriel Steg

  9. Hôpital de la Tour, Geneva, Switzerland

    Philip Urban

  10. Cardiocentro Ticino Institute and Università della Svizzera italiana (USI), Lugano, Switzerland

    Marco Valgimigli

  11. Department of Cardiology, Bern University Hospital, Bern, Switzerland

    Stephan Windecker

  12. University of Florida College of Medicine, Jacksonville, FL, USA

    Dominick J. Angiolillo

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Contributions

D.C. and D.J.A. researched data for the article and wrote the manuscript. All the authors contributed substantially to discussions of content and reviewed and/or edited the manuscript before submission.

Corresponding author

Correspondence to Dominick J. Angiolillo.

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Competing interests

D.C. reports advisory board or speaker’s honoraria from Amgen, Biotronik, Boehringer Ingelheim, Daiichi Sankyo, Menarini and Sanofi. D.L.B. discloses the following relationships: advisory board of Cardax, CellProthera, Cereno Scientific, Elsevier Practice Update Cardiology, Level Ex, Medscape Cardiology, MyoKardia, PhaseBio, PLx Pharma and Regado Biosciences; board of directors of Boston VA Research Institute, Society of Cardiovascular Patient Care and TobeSoft; chair of AHA Quality Oversight Committee; membership of data monitoring committees for the Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute, for the PORTICO trial, funded by St. Jude Medical, now Abbott), the Cleveland Clinic (including for the ExCEED trial, funded by Edwards), Contego Medical (chair, PERFORMANCE 2), Duke Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine (for the ENVISAGE trial, funded by Daiichi Sankyo) and Population Health Research Institute; honoraria from ACC (Senior Associate Editor, Clinical Trials and News, ACC.org; Vice-Chair, ACC Accreditation Committee), the Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute; RE-DUAL PCI clinical trial steering committee funded by Boehringer Ingelheim; AEGIS-II executive committee funded by CSL Behring), Belvoir Publications (Editor in Chief, Harvard Heart Letter), Canadian Medical and Surgical Knowledge Translation Research Group (clinical trial steering committees), Duke Clinical Research Institute (clinical trial steering committees, including for the PRONOUNCE trial, funded by Ferring Pharmaceuticals), HMP Global (Editor-in-Chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (Guest Editor, Associate Editor), K2P (Co-Chair, interdisciplinary curriculum), Level Ex, Medtelligence/ReachMD (CME steering committees), MJH Life Sciences, Population Health Research Institute (for the COMPASS operations committee, publications committee, steering committee, and USA national co-leader, funded by Bayer), Slack Publications (Chief Medical Editor, Cardiology Today’s Intervention), Society of Cardiovascular Patient Care (Secretary/Treasurer) and WebMD (CME steering committees); others including Clinical Cardiology (Deputy Editor), NCDR-ACTION Registry Steering Committee (Chair), VA CART Research and Publications Committee (Chair); research funding from Abbott, Afimmune, Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, Cardax, Chiesi, CSL Behring, Eisai, Ethicon, Ferring Pharmaceuticals, Forest Laboratories, Fractyl, HLS Therapeutics, Idorsia, Ironwood, Ischemix, Lexicon, Lilly, Medtronic, MyoKardia, Owkin, Pfizer, PhaseBio, PLx Pharma, Regeneron, Roche, Sanofi, Synaptic and The Medicines Company; royalties from Elsevier (editor, Cardiovascular Intervention: A Companion to Braunwald’s Heart Disease); site co-investigator for Biotronik, Boston Scientific, CSI, St. Jude Medical (now Abbott) and Svelte; trustee for ACC; and unfunded research for FlowCo, Merck, Novo Nordisk and Takeda. C.M.G. reports research support from Johnson & Johnson and consulting support from AstraZeneca, Johnson & Johnson, Janssen and Bayer. T.K. reports research grant from Abbott Vascular and Boston Scientific. R.M. reports institutional research grants from Abbott Laboratories, Abiomed, Applied Therapeutics, AstraZeneca, Bayer, Beth Israel Deaconess, Bristol Myers Squibb, CERC, Chiesi, Concept Medical, CSL Behring, DSI, Medtronic, Novartis Pharmaceuticals and OrbusNeich, Zoll; consultant fees from Boston Scientific, Cine-Med Research, Janssen Scientific Affairs, Medscape/WebMD; consultant fees paid to the institution from Abbott Laboratories, Abiomed (spouse), Bayer (spouse), Beth Israel Deaconess, Bristol Myers Squibb, CardiaWave, Chiesi, Concept Medical, DSI, Duke University, Idorsia Pharmaceuticals, Medtronic, Novartis and Spectranetics/Philips/Volcano Corp; equity of <1% from Applied Therapeutics, Elixir Medical, STEL and CONTROLRAD (spouse); consulting (no fee) for Regeneron Pharmaceuticals; and Associate Editor for ACC and AMA. P.G.S. discloses the following relationships: research grant from Amarin, Bayer, Sanofi and Servier; speaking or consulting fees from Amarin, Amgen, AstraZeneca, Bayer/Janssen, Bristol Myers Squibb, Idorsia, Myokardia, Novartis, Novo Nordisk, PhaseBio, Pfizer, Regeneron, Sanofi and Servier. P.U. reports consulting honoraria from Biosensors and MedAlliance, and CEC honoraria from Edwards Lifesciences and Cardialysis; honoraria as medical co-director at CERC; and is a shareholder of MedAlliance. S.W. reports research and educational grants to the institution from Abbott, Amgen, Bayer, Biotronik, Boston Scientific, Bristol Myers Squibb, Cardinal Health, Cardiovalve, CSL Behring, Daiichi Sankyo, Edwards Lifesciences, Johnson & Johnson, Medtronic, Querbet, Polares, Sanofi, Terumo and Sinomed, and unpaid advisory board membership and/or unpaid membership of the steering/executive group of trials funded by Abbott, Abiomed, Amgen, Astra Zeneca, Biotronik, Boston Scientific, Bristol Myers Squibb, Cardiovalve, Edwards Lifesciences, MedAlliance, Medtronic, Novartis, Polares, Sinomed, V-Wave and Xeltis, but has not received personal payments from pharmaceutical companies or device manufacturers; he is also member of the steering/executive committee group of several investigator-initiated trials that receive funding from industry without impact on his personal remuneration; he is an unpaid member of the Pfizer Research Award selection committee in Switzerland. D.J.A. has received payment as an individual as a consulting fee or honorarium from Abbott, Amgen, Aralez, AstraZeneca, Bayer, Biosensors, Boehringer Ingelheim, Bristol Myers Squibb, Chiesi, Daiichi-Sankyo, Eli Lilly, Haemonetics, Janssen, Merck, PhaseBio, PLx Pharma, Pfizer, Sanofi and The Medicines Company, and for participation in review activities from CeloNova and St. Jude Medical; has received institutional payments as grants from Amgen, AstraZeneca, Bayer, Biosensors, CeloNova, CSL Behring, Daiichi-Sankyo, Eisai, Eli-Lilly, Gilead, Idorsia, Janssen, Matsutani Chemical Industry Co., Merck, Novartis, Osprey Medical, Renal Guard Solutions and the Scott R. MacKenzie Foundation. All the other authors report no competing interests.

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Nature Reviews Cardiology thanks D. Alexopoulos, J. P. Collet and K. Huber for their contribution to the peer review of this work.

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Capodanno, D., Bhatt, D.L., Gibson, C.M. et al. Bleeding avoidance strategies in percutaneous coronary intervention. Nat Rev Cardiol 19, 117–132 (2022). https://doi.org/10.1038/s41569-021-00598-1

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