Management of antithrombotic therapy in patients at high bleeding risk after percutaneous coronary intervention for acute coronary syndromes: a case report

BACKGROUND: Choosing antithrombotic therapy for patients at high bleeding risk, particularly those requiring long-term anticoagulant therapy, who have acute coronary syndromes (ACS) and/or undergoing percutaneous coronary intervention (PCI) is becoming increasingly complex. CASE SUMMARY: A 78-year-old women was hospitalized with chest pain and a diagnosis of non-ST-elevation ACS was made. It was decided that the patient should undergo coronary angiogram with a view for angioplasty. Subsequently, she underwent successful PCI to the left anterior descending artery. Shortly after PCI, she was noted to be in atrial fibrillation. Furthermore, she had per rectal bleeding and acute kidney injury, which were managed conservatively. Aspirin and ticagrelor were stopped and she was discharged on dual antithrombotic therapy with clopidogrel and apixaban. DISCUSSION: Available evidence, driven mainly from expert consensus documents, advocates a case-by-case comprehensive evaluation that integrates patient- and procedure-related factors to assess patients for thrombotic and bleeding tendencies to identify those who may gain most net clinical benefit of antithrombotic combination therapy. In general, if thrombotic drivers prevail, an augmented antithrombotic regime with a view for a longer duration should be planned, and if bleeding drivers prevail, a de-escalated regime with a view for a shorter duration should be sought.