Dual antiplatelet therapy in patients at high bleeding risk: less is more—more or less

Risk-based antithrombotic strategies after percutaneous coronary intervention (PCI). Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor is indicated for patients undergoing PCI. Applying a risk stratification approach that considers the risk of both thrombosis and bleeding, each individual patient can be managed with a tailored antithrombotic regimen. If the two risks substantially equipoise, standard DAPT is indicated (i.e. aspirin plus a P2Y12 receptor inhibitor for 6 or 12 months, based on the clinical scenario). In patients with a prevailing thrombotic risk (left part of the figure), the intensity of the antithrombotic therapy can be increased by administering DAPT for a prolonged duration or by prescribing a dual-pathway inhibition therapy (i.e. ASA plus rivaroxaban 2.5 mg twice daily). Conversely, when the bleeding risk prevails (right part of the figure), the intensity of the antithrombotic therapy can be decreased by de-escalation to a reduced intensity regimen (i.e. switching from a potent P2Y12 receptor inhibitor to clopidogrel or reducing the P2Y12 receptor inhibitor dose) or by early discontinuation of DAPT with transition to a monotherapy with either ASA or a P2Y12 receptor inhibitor. Abbreviations: ASA, acetylsalicylic acid; BID, bis in die (twice daily); C75, clopidogrel 75 mg; P2Y12-i, P2Y12 receptor inhibitor; OD, once daily; P10, prasugrel 10 mg; R2.5, rivaroxaban 2.5 mg; T60, ticagrelor 60 mg; T90, ticagrelor 90 mg.