Indian Interventional Cardiologists' Perspectives on De-escalating Dual to Single Antiplatelet Therapy in High...

Managing thrombotic and hemorrhagic risks associated with dual antiplatelet therapy (DAPT) in patients with a high bleeding risk (HBR) is challenging, especially in post-percutaneous coronary intervention (PCI) patients. Transitioning from DAPT to single antiplatelet therapy (SAPT) aims to reduce bleeding complications while ensuring sufficient ischemic protection. This study explored Indian interventional cardiologists' views on de-escalation strategies in HBR patients, considering bleeding risk factors, including Indian-specific risks, such as tropical diseases and other comorbidities.

A cross-sectional questionnaire-based survey was conducted from June 2024 to July 2024 among 400 interventional cardiologists in India. A structured, pre-validated questionnaire was used to gather data on the perceived prevalence of HBR in routine practice, key HBR factors specific to Indian patients (such as frailty, comorbidities, and tropical diseases), preferred SAPT agents after DAPT, perceived bleeding risk profiles of antiplatelet agents, and barriers to implementation of de-escalation. Participation was voluntary and anonymous. Responses were analyzed using descriptive statistics and reported as frequencies and proportions.

Of the 375 interventional cardiologists, 193 (51.47%) reported an HBR prevalence of less than 10%, and 250 (66.67%) believed that gastrointestinal (GI) bleeding was the most common complication in patients receiving DAPT. The main HBR factors included frailty, reported by 326 (86.90%) cardiologists, chronic kidney disease (CKD) stage 3 or severe, reported by 319 (85.1%) cardiologists, and liver cirrhosis with portal hypertension, reported by 324 (86.4%) interventional cardiologists. After DAPT, 128 (34.13%) cardiologists preferred clopidogrel 75 mg, and 107 (28.53%) preferred aspirin 75 mg. Clopidogrel was seen as the least likely to cause bleeding by 179 (48.00%) interventional cardiologists, with 80 (21.33%) rating it as the best option for HBR patients de-escalating from DAPT to SAPT.

This study presents Indian interventional cardiologists' perspectives on de-escalation strategies, including transitioning from DAPT to SAPT, to reduce bleeding complications, while ensuring adequate ischemic protection in patients with HBR post-PCI. Interventional cardiologists have outlined criteria for identifying critical HBR factors relevant to the Indian population. Clopidogrel was the most preferred medication for transitioning to SAPT in HBR patients. Simplified Indian bleeding risk scoring tools and tailored approaches are essential for improving DAPT management in patients with HBR.