Bleeding versus ischemic risk during dual antiplatelet therapy on patients with acute coronary syndromes undergoing percutaneous coronary intervention

The benefit of dual antiplatelet treatment is well established among patients admitted with acute coronary syndromes (ACS) with or without ST-segment elevation undergoing percutaneous coronary intervention (PCI). However, bleeding is associated with an increased risk of in-hospital and long-term mortality. The aim of this analysis was to evaluate the ischemic and bleeding risk between clopidogrel and newer oral antiplatelet agents in the real world among patients with ACS undergoing PCI. Methods: Consecutive patients with ACS from January 2012 until December 2013 were included in the analysis. Patients who received thrombolysis, glycoprotein 2b3a inhibitors and chronic anticoagulants were excluded. Follow-up was done for a median of 271 days (IQR 150-385 days). Results: A total of 689 patients were included in the analysis. Clinical presentation was as follows: 40.3% NSTEMI, 30.6% STEMI while the rest were unstable angina patients. From the entire population, clopidogrel was indicated in 48.1%, prasugrel in 37.9% and ticagrelor in 13.3% while STEMI patients received prasugrel in 43% (p 0.001). CRUSADE score was similar among the three groups (p0.09). Total bleeding events were significantly different among groups (prasugrel 17.3% vs. ticagrelor10.1% vs. clopidogrel 5%, p=0.01). Major and/or life threatening bleeding was significantly different among groups ( prasugrel 6.9%, ticagrelor 3.8%, clopidogrel 2.6%, p=0.05). Total bleeding adjusted by type of acute coronary syndrome was significantly higher with prasugrel against clopidogrel (HR (CI95%) 2.67 (1.67-4.27) p<0.001) and was not significantly different with ticagrelor vs. clopidogrel (HR 1.71 (0.86-3.41) p 0.1). By logistic regression, total bleeding was independently associated with STEMI (OR 2.25, p 0.002), use of prasugrel (OR 2.31, p 0.001), and creatinine clearance < 60 ml/min (OR 1.74, p 0.03). Meanwhile, ischemic events occurred similarly regardless of the antiplatelet therapy (clopidogrel 10.8%, prasugrel 7.6% and ticagrelor 8.4%, p 0.23). Conclusions: Patients with ACS undergoing PCI have a significant risk of bleeding during follow-up. With the improvement in angioplasty techniques and stents, the duration and the choice of the dual antiplatelet treatment might be balanced assessing ischemic and bleeding risks individually.