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Bleeding associated with the management of acute coronary syndromes
  1. Kalpa De Silva1,
  2. Aung Myat2,3,
  3. James Cotton4,
  4. Stefan James5,
  5. Anthony Gershlick6,7,
  6. Gregg W Stone8
  1. 1Department of Cardiology, King's College Hospital, London, UK
  2. 2Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
  3. 3Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK
  4. 4Department of Cardiology, Heart and Lung Centre, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
  5. 5Department of Medical Sciences and Uppsala Clinical Research Centre, Uppsala University, Uppsala, Sweden
  6. 6Department of Cardiology, University of Leicester, Leicester, UK
  7. 7NIHR Leicester Cardiovascular Biomedical Research Centre, Leicester, UK
  8. 8Department of Cardiology, Columbia University Medical Center, New York Presbyterian Hospital, New York City, New York, USA
  1. Correspondence to Dr Gregg W Stone, Department of Cardiology, Columbia University Medical Centre, New York Presbyterian Hospital, 161 First Washington Avenue, Herbert Irving Pavilion, 6th Floor, New York, NY 10032, USA; gs2184{at}

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Learning objectives

  • Enhance understanding with regard to modes of risk stratification alongside consideration of ischaemic versus bleeding sequalae.

  • To demonstrate the prognostic importance of bleeding complications

  • Synthesis of strategies to minimise bleeding complications.


Rupture or erosion of a coronary artery atheroma exposes flowing blood to the prothrombotic contents of the plaque, resulting in platelet activation and subsequent thrombus formation. If this process results in reduced coronary blood flow, the patient may present with an acute coronary syndrome (ACS). Total thrombotic occlusion generally results in ST-segment elevation myocardial infarction (STEMI), whereas incomplete occlusion (or extensive collateralisation) is more likely to present as non-STEMI or unstable angina without evidence of myonecrosis (collectively non-ST-segment elevation ACS (NSTE-ACS)). Revascularisation, most commonly with percutaneous coronary intervention (PCI) is standard of care in ACS, as it restores myocardial perfusion by addressing both the thrombotic obstruction and the underlying coronary stenosis. However, adjunctive pharmacological treatment after revascularisation, or in patients managed conservatively, may be of equal importance in influencing prognosis.1–3

Contemporary adjunctive antithrombotic therapy in ACS includes potent antiplatelet and anticoagulant agents, each of which carries the risk of bleeding. The frequency and implications of haemorrhagic complications must be factored into the risk-benefit analysis for each patient since PCI is increasingly performed in complex subgroups such as those with renal dysfunction, underlying anaemia and the elderly, cohorts with inherently increased bleeding risk.4 ,5 Furthermore, although the absolute bleeding risk will vary according to individual patient characteristics, the overall relative bleeding risk increases with the number, potency and duration of agents co-administered. For example, those patients with ACS, already taking chronic oral anticoagulation (OAC) for stroke protection in atrial fibrillation, are then treated with dual antiplatelet therapy (DAPT) (so-called ‘triple therapy’).6 ,7

There is extensive evidence in the published literature that demonstrates major bleeding to …

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  • Contributors KDS, AG and GWS wrote and edited the manuscript. AM, JC and SJ all helped edit the manuscript at various stages.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.