Management of antithrombotic therapy after bleeding in patients with coronary artery disease and/or atrial fibrillation: expert consensus paper of the European Society of Cardiology Working Group on Thrombosis

Bleeding is a frequent complication of the management of patients with coronary artery disease (CAD), especially those presenting with acute coronary syndromes (ACS) or undergoing percutaneous coronary intervention (PCI), and of patients with atrial fibrillation (AF). Randomized trials have shown a risk of major bleeding of 1–8% at 30 days in ACS patients,1–5 and of 2–5% per year in patients with AF treated with oral anticoagulants (OACs).6 Observational studies suggest that bleeding risk is even higher.7 Major bleeding is associated with a subsequent increase in both short- and long-term mortality.7–13 Even minimal bleeding may have prognostic importance because it frequently leads to disruption of antithrombotic therapy.14,15 Several mechanisms have been put forward to explain the relationship between major bleeding and increased mortality ( Figure 1 ). The overlap in risk factors for bleeding and ischaemic events means that patients who are more likely to suffer from bleeding complications of antithrombotic therapy also tend to be at higher risk of thrombotic events.16 Discontinuation of antithrombotic drugs may lead to an increased rate of thrombotic events due to the progressive recovery of platelet function and coagulation activity.17–19 In addition, bleeding may provoke prothrombotic responses beyond those related to discontinuation of antithrombotic drugs.20,21 Clearly, balancing the risks of further bleeding vs. potentially fatal thrombotic events is critical for decisions about if and when to restart antithrombotic therapy after bleeding. Figure 1 Hypothetical mechanisms linking bleeding to thrombotic events and death. Numerous risk factors for bleeding are also risk factors for myocardial infarction, stroke and death (large arrows). VTE, venous thromboembolism. Although several recommendations have been published dealing with the acute management of bleeding in patients treated with antithrombotic drugs,22–24 there is an unmet need for guidance on how to manage antithrombotic therapy after bleeding …