Assessment of bleeding risk in patients with coronary artery disease on dual antiplatelet therapy. A systematic review.
Patients with coronary artery disease are usually treated with dual antiplatelet therapy (DAPT) after percutaneous coronary intervention. Patients on DAPT are at risk of both ischaemic and bleeding events. Although side-lined for a long time, real-life studies have shown that both the incidence and the associated morbidity and mortality of out-of-hospital bleeding are high. This indicates that prevention of (post-interventional) bleeding is as important as prevention of ischaemia. For this purpose it is crucial to reliably identify patients with a high bleeding risk. In order to postulate an algorithm, which could help identifying these patients, we performed a systematic review to determine the value of previously proposed prognostic modalities for bleeding. We searched and appraised the following tools: platelet function tests, genetic tests, bleeding scores and questionnaires and haemostatic tests. Most studies indicated that low on-treatment platelet reactivity (LTPR), as measured by several platelet function tests, and the carriage of CYP2C19*17 allele were independent risk factors for bleeding. A bleeding score also proved to be helpful in identifying patients at risk. No studies on haemostatic tests were retrieved. Several patient characteristics were also identified as independent predictors of bleeding, such as older age, female sex and renal failure. Combining these risk factors we propose an algorithm that would hypothetically facilitate identification of those patients at highest risk, warranting prevention measures for bleeding. This could be a starting point for further research concerning the topic.
Minka Vries, CARIM, Universiteitssingel 50, 6229 ER Maastricht, P. O. Box 616, 6200 MD Maastricht, The Netherlands, Tel.: +31 433881542, Fax: +31 43884159, E-mail: m.vries@maastrichtuniversity.nl.
Minka J A
MJ
Vries
Paola E J
PE
van der Meijden
Yvonne M C
YM
Henskens
Arina J
AJ
ten Cate-Hoek
Hugo
H
ten Cate
D000465:Algorithms; D003324:Coronary Artery Disease / Q000097:blood / Q000175:diagnosis / Q000628:therapy*; D019091:Critical Pathways; D065731:Cytochrome P-450 CYP2C19 / Q000235:genetics / Q000378:metabolism; D003661:Decision Support Techniques; D004351:Drug Resistance; D004359:Drug Therapy, Combination; D005838:Genotype; D006470:Hemorrhage / Q000139:chemically induced*; D006801:Humans; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects; D010597:Pharmacogenetics; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage / Q000009:adverse effects* / Q000493:pharmacokinetics; D010979:Platelet Function Tests; D011237:Predictive Value of Tests; D018570:Risk Assessment; D012307:Risk Factors; D016896:Treatment Outcome
D010975:Platelet Aggregation Inhibitors; C045793:CYP2C19 protein, human; D065731:Cytochrome P-450 CYP2C19
Dual antiplatelet therapy; bleeding; coronary artery disease; prognostic tests