Strategies to Reduce Bleeding Risk in Acute Coronary Syndromes and Percutaneous Coronary Intervention: New and Emerging Pharmacotherapeutic Considerations

Bleeding is a well‐recognized complication among patients who undergo percutaneous coronary intervention for acute coronary syndromes. Patients who bleed in this setting have higher morbidity, mortality, and resource use. Several bleeding avoidance strategies have been identified including the use of certain pharmacologic interventions; however, the antithrombotic landscape for this patient population is evolving rapidly. Numerous practical issues are related to the appropriate selection and dosing of antiplatelets and anticoagulants, as well as their combinations, that may have an impact on bleeding. Thus we reviewed the recent evidence that describes the use of these agents and provide recommendations on the appropriate use of antiplatelets and anticoagulants in the context of current practice and guideline recommendations. Opportunities exist to reduce bleeding complications through the adoption of bleeding avoidance strategies and appropriate use of antiplatelets and anticoagulants. Pharmacist expertise is critical in the appropriate selection, dosing, and monitoring of these medications to improve patient safety as it relates to bleeding potential. Clinical outcomes evaluating combinations of antiplatelets and anticoagulants, particularly with novel anticoagulants, are ongoing as are studies that incorporate use of genotype and phenotype into antithrombotic decision making.