Reassessing PCI Timing in High Bleeding Risk Patients: Evidence, Strategies, and Outcomes

Area of Science:

• Cardiology
• Interventional Cardiology
• Vascular Medicine

Background:

• Percutaneous coronary intervention (PCI) in patients with high bleeding risk (HBR) poses a significant clinical challenge, necessitating a delicate balance between preventing ischemic events and minimizing bleeding complications.
• The Academic Research Consortium High Bleeding Risk (ARC-HBR) criteria help identify HBR patients, but optimal timing, procedural tactics, and antithrombotic strategies remain unclear.

Purpose of the Study:

• To review and synthesize current evidence on PCI in HBR patients, focusing on procedural strategies and antithrombotic regimens.
• To evaluate the safety and efficacy of different PCI approaches and treatment durations in HBR populations across various clinical scenarios.

Main Methods:

• Comprehensive review of randomized controlled trials, large registries, and meta-analyses involving HBR patients undergoing PCI.
• Analysis of data concerning procedural choices (radial vs. femoral access), device selection (drug-coated balloons, polymer-free drug-eluting stents), and dual antiplatelet therapy (DAPT) duration.
• Examination of PCI timing strategies in different clinical settings, including stable coronary artery disease, acute coronary syndromes (ACS), ST-elevation myocardial infarction (STEMI), and specific high-risk states.

Main Results:

• Evidence supports abbreviated DAPT regimens (1-3 months) when combined with bleeding-sparing techniques and devices, particularly beneficial for patients with high ischemic burden (e.g., GRACE score >140).
• Early invasive management in ACS patients undergoing PCI was associated with reduced ischemic events and shorter hospital stays without increased major bleeding.
• Delayed PCI is recommended for patients with active bleeding, recent thrombolysis, or severe coagulopathy.

Conclusions:

• PCI in HBR patients can be performed safely and effectively through individualized, evidence-based strategies for procedural timing and antithrombotic therapy.
• Limitations include the underrepresentation of ARC-HBR patients in clinical trials and the lack of standardized protocols for bleeding risk-tailored PCI timing.
• Future research should focus on integrating biomarker-driven DAPT modulation and artificial intelligence for optimizing outcomes in this high-risk population.