Table 20.

Management scheme for dual antiplatelet therapy in the event of the most common forms of haemorrhage

Bleeding severity	Minimal (does not require changes in therapy or medical intervention)	Mild (requires medical consultation but no intervention or hospitalisation)	Moderate (significant anaemisation without haemodynamic instability)	Severe (drop in Hb >5 g/dl without haemodynamic instability)	Life-threatening (any bleeding is potentially lethal)
Type of bleeding	Mild epistaxis, modest conjunctival bleeding, mild bruising	Major or recurrent epistaxis, moderate conjunctival bleeding, GI bleeding, GU or mild haemoptysis without significant anaemia	GU, GI bleeding with significant anaemia and/or need for transfusion	Bleeding of any kind with anaemia >5 g/dl, or uncontrollable GU bleeding (prostate, bladder)	Bleeding of any kind with serious anaemisation and/or haemodynamic and/or severe site instability (intracranial)
DAPT management	Continue DAPT	Continue the DAPT	Consider administering SAPT, preferably with P2Y12 inhibitor	Consider administering SAPT, preferably with P2Y12 inhibitor or suspension of the DAPT	Suspension of DAPT
Measures	Reassure the patient, explain the importance of DAPT, prevent recurrences	Treat the causes of bleeding, asses the possibility of reducing DAPT duration or reducing inhibition	Treat the cause of bleeding (interventional endoscopy), iv PPI in case of GI bleeding, assess the possibility of reducing DAPT duration or reducing inhibition	Transfuse RBCs for Hb <7-8 g/dl; surgical/endoscopic haemorrhage treatment; consider the transfusion of platelets; once bleeding has ceased, reassess the possibility of restarting DAPT/SAPT, possibly with clopidogrel as an alternative to prasugrel/ticagrelor and reassess relevant duration	RBC Transfusion, volume expansion, surgical/endoscopic/endovascular treatment, consider indefinite suspension of DAPT, consider transfer to hospital with 24-hour cath lab

DAPT, dual antiplatelet therapy; GI, gastrointestinal; RBCs, red blood cells; GU, genitourinary; Hb, haemoglobin; PPI, proton pump inhibitors; SAPT, single antiplatelet therapy.

Society legend: ANMCO -Italian Association of Hospital Cardiologists; ANCE -Italian Association of Territorial Cardiology; ARCA-Regional Ambulatory Cardiologists Association; ATVB- Working Group on Atherosclerosis, Thrombosis and Vascular Biology; GICR-IACPR-Italian Group of Rehabilitation and Preventive Cardiology; GIEC- Italian Group of Emergency Cardiology; GISE -Italian Society of Interventional Cardiology; ITAHFA – Italian Heart Failure Association; SICP- Italian Society of Pediatric Cardiology; SICOA - Italian Society of Accredited Cardiology Hospital Care (SICOA); SIT - Italian Society of Digital Medicine & Telemedicine