The impact of bleeding in patients with acute coronary syndromes: How to optimize the benefits of treatment and minimize the risk

Recurrent ischemic events after an acute coronary syndrome (ACS) remain common. Antithrombotic therapy with coronary revascularization reduces the frequency of such life-threatening events. However, with the greater use of antithrombotic medications and early revascularization, bleeding has become an increasingly important problem. Not only does bleeding result in an immediate threat, but it is also associated with increased coronary artery disease mortality and reinfarction, both in the short and long term. Older patients and women, as well as patients with anemia, renal dysfunction, high-risk ACS, diabetes, hypertension and those undergoing invasive procedures, are at especially high risk for bleeding. Major bleeding is associated with a 60% increased risk of in-hospital death, and a fivefold increase in one-year mortality and reinfarction. However, the causal link between bleeding and increased coronary artery disease events is unproven. Although there is no proof that reducing bleeding events improves outcomes, the current paradigm for the management of ACS is a strategy to minimize recurrent ischemic events but also to minimize the risk of bleeding. Such a strategy includes matching the ACS risk to the most appropriate treatment, assessing the bleeding risk, using vascular access techniques to minimize bleeding, selecting the antithrombotic agent that is best for the patient, minimizing the duration of exposure to antithrombotic agents, using the correct dose of medications, recognizing the early signs of bleeding and using gastro-protective agents to minimize upper gastrointestinal bleeding.