Mortality From Bleeding Versus Myocardial Infarction: Loosening A Strand of the Antithrombotic Therapy “Gordian Knot”

Decades of clinical trial advancements in antithrombotic therapies have delivered improvements in long-term survival following acute coronary syndrome (ACS). The interdependency between percutaneous coronary intervention (PCI) and dual antiplatelet therapy combined with the clinical concern surrounding the catastrophic consequences of dreaded stent thrombosis has focused physicians on the need to “manage the stent.” Yet clinical guideline recommendations for balancing the risks for recurrent ischemic and bleeding events among patients with ACS not receiving coronary revascularization following events have received relatively less attention (1). Among these patients, the prevalence of factors contributing to bleeding and ischemic events are often higher and intermixed. Hence, when seeking to optimize outcomes for patients transitioning from the acute to the chronic phase of coronary artery disease, cardiologists are faced with a diverse array of therapeutic choices, while needing to weigh a wide array of comorbidities, as well as whether patients received coronary stents. These complexities are hard to unravel with standard guidelines.