Choosing an antiplatelet strategy in patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS) at high bleeding risk (HBR), undergoing percutaneous coronary intervention (PCI), is complex given that one must balance the risk of thrombosis with bleeding events. Since the most recent European guidelines were published in 2020, a number of important original research articles and meta-analyses have been published and the question of what strategy should be used in HBR patients is somewhat controversial; accordingly, practice is expected to vary widely. To assess the degree of practice variation, as well as general attitudes towards choice and duration of antiplatelet therapy in the HBR population, a unique, open-source approach (crowdsourcing), driven primarily through social media, was used to survey a small, global cross-section of prescribers, on their attitudes and practices in the post-PCI setting.
Five-hundred and fifty-nine professionals from 70 countries (the ‘crowd’) completed questionnaires regarding antiplatelet clinical practice in post-PCI NSTE-ACS patients at HBR. Using a threshold of 75% to define ‘agreement’, there was strong agreement for use of monotherapy with either aspirin or a P2Y12 inhibitor following an initial course of dual antiplatelet therapy (DAPT), within the first year (94%). No agreement was reached on the optimal duration of DAPT or choice of monotherapy: responses were in equipoise for shorter (≤3 months, 51%) or longer (≥6 months, 46%) DAPT duration, and monotherapy choice (45% aspirin; 53% P2Y12 inhibitor). Most respondents said they use guideline-directed tools to assess risk, although clinical judgement was preferred by 32% for assessing bleeding risk and by 46% for thrombotic risk, over any specific tool.
The crowdsourcing methodology showed potential as a tool to assess current practice and variation on a global scale and to achieve a broad demographic representation. These preliminary results indicate a high degree of variation with respect to duration of DAPT, monotherapy drug of choice following DAPT and how thrombotic and bleeding risk are assessed.
Bhatt DL, Kaski JC, Delaney S, Alasnag M, Andreotti F, Angiolillo DJ, Ferro A, Gorog DA, Lorenzatti AJ, Mamas M, McNeil J, Nicolau JC, Steg PG, Tamargo J, Tan D, Valgimigli M. Results of an international crowdsourcing survey on the treatment of non-ST segment elevation ACS patients at high-bleeding risk undergoing percutaneous intervention. Int J Cardiol. 2021 May 15:S0167-5273(21)00824-X. Pubmed: 34000356.