How to choose antithrombotic therapy for patients with high bleeding risk

 It is well known that high bleeding risk（HBR）seriously affects the clinical prognosis of patients, which must be considered in clinical decision-making.With the improvement of stent technology and the individualization of antithrombotic therapy after the percutaneous coronary intervention (PCI) , for this special population, how to optimize PCI and improve antiplatelet therapy strategy after PCI are the focus of attention. This journal specially invited Roxana Mehran,MD,of Mount Sinai Hospital, New York, to conduct in-depth discussions on"the best stent and antiplatelet therapy strategy for patients with HBR".

 International Circulation: There are above 40% patients with higher blood risk in those undergoing PCI. For this special population, what stent selection strategy should we adhere to?

 Professor Roxana Mehran: As you stated, high bleeding risk patients are common. We see them every day. They are elderly; they have had prior stroke; or a patient on an oral anticoagulant; frail;  female; who has had a prior bleeding episode or is anemic - these are all parts of high bleeding risk patients. In fact, we have an ARC-HBR group that identifies these patients using major and minor criteria. We see them every day in PCI, and when we do, we have to take into account their ischemic and their bleeding risk, and make important judgments about the antiplatelet regimens. Often in these patients, we will use clopidogrel instead of ticagrelor, and if we choose a potent agent, it would be for a short duration. Importantly, we reduce the duration of therapy, and sometimes even think about dropping aspirin as one of the novel strategies to reduce bleeding without increasing ischemic events.

  International Circulation: The antithrombotic therapy strategies should balance the risk of bleeding and ischemia . How should we select the best antiplatelet therapy strategy or regimen for those patients based on the results of relevant clinical studies?

 Professor Roxana Mehran: I think the other thing is that what we do in our procedure for high bleeding risk patients is very important. We usually choose thin-strut stents, and try to reduce the number of stents. We can use FFR- or IFR- or QFR-guided PCI to make sure we are stenting the regions that need to be stented. We also use intravascular imaging. I think that those are really important. As far as the antithrombotic regimens, I already discussed that we would use a short duration of dual antiplatelet therapy, and sometimes even drop aspirin.

 International Circulation: question For patients with high blood risk, what measures do you usually take to prevent bleeding events in your clinical practice? Would you please share your experiences?

 Professor Roxana Mehran:  I think whenever you have a high bleeding risk patient, or even for all patients, we should use bleeding avoidance strategies. From the get-go, we would use a radial approach, we would us heparin or bivalirudin, we would try to avoid GP IIb/IIIa inhibitors in these patients, and we would be very careful about stent selection, as well as dual antiplatelet therapies.

 Most importantly, we would talk to them about the risk of bleeding so that they can understand the importance of both ischemic and bleeding risks - they are both just as important. Once we educate our patients then we have a really good way forward in avoiding bleeding complications in these patients by using radial and going to a shortened duration of dual antiplatelet therapies (abbreviating DAPT), and working closely with our referring physicians to make sure they also understand what the strategies are.