How Do We Manage Antiaggregation in BARC I Bleeding after AMI?

Dual antiplatelet therapy (DAPT) after acute myocardial infarction (AMI) has been shown useful to reduce thrombotic events, but one of its downsides is bleeding, especially in elderly patients.

BARC bleeding type I, also called nuisance bleeding (NB), is of low frequency, but its evolution and impact remain unclear, as does its management.

A subanalysis of the TALOS-AMI was carried out. This study included 2583 patients receiving DAPT after AMI with ASA and ticagrelor. 416 of these patients (16.1%) presented NB.

Patients presenting NB were younger (58 vs. 60 p=0.01) and showed no difference in comorbidities. Kidney function was conserved and there were no differences as regards treated vessel or number of implanted stents.

De-escalation was from ticagrelor to clopidogrel.

At one-year followup, NB was not associated to increased BARC bleeding 2, 3, or 5 (hazard ratio [HR]‚ 1.29 [95% CI‚ 0.7–2.14]) or major cardiovascular events (HR, 1.94 [95% CI, 1.08–3.48]; P=0.026).

De-escalation from ticagrelor to clopidogrel reduced the incidence of bleeding compared against ticagrelor plus ASA in bleeding type I (HR‚ 0.31 [95% CI‚ 0.10–0.92]).

There was no increase in cardiovascular events at de-escalation.

Conclusion

Nuisance bleeding (BARC type I) is frequent after AMI the first month after DAPT with ticagrelor and was associated to early bleeding. De-escalation after NB might reduce bleeding events with no increase in ischemic events.