Percutaneous coronary intervention in high bleeding risk patients: a review of contemporary management strategies

INTRODUCTION: High bleeding risk (HBR) affects over one-third of patients undergoing percutaneous coronary intervention (PCI) and is associated with elevated mortality due to both hemorrhagic and ischemic complications. Optimizing the management of these patients remains a critical challenge in contemporary interventional cardiology. AREAS COVERED: This review summarizes advances in bleeding risk assessment and management strategies in HBR patients. Literature was evaluated regarding validated risk tools (ARC-HBR, PRECISE-HBR), procedural approaches (radial access, intravascular imaging-guided PCI), device selection (contemporary drug-eluting and polymer-free stents, drug-eluting balloons), and pharmacologic optimization (shortened dual antiplatelet therapy, minimization of triple therapy, proton pump inhibitor prophylaxis). Emerging approaches, including artificial intelligence-enhanced risk prediction, biomarker-based phenotyping, and pharmacogenomic-guided antiplatelet selection, are also discussed. Dedicated HBR care pathways and multidisciplinary programs supporting best-practice implementation are highlighted. EXPERT OPINION: Despite contemporary strategies reducing bleeding risk, HBR patients continue to experience disproportionate mortality. Precision medicine approaches, including continuous risk quantification, next-generation antithrombotics with improved safety, and standardized, data-driven HBR management frameworks, are needed to further optimize outcomes and guide future trials in this high-risk population.