Table 4.
Definition and management of bleeding in patients on dual antiplatelet therapy (modified from European Guidelines [7]). DAPT, dual antiplatelet therapy; GI, gastrointestinal; GU, genitourinary; Hb, hemoglobin; i.v., intravenous; Plt, Platelets; PPI, proton pump inhibitor; RBC, red blood cell; SAPT, single antiplatelet therapy.
| Severity Grade | Definition | Examples | DAPT Management | Other Recommendations |
|---|---|---|---|---|
| Trivial | Any bleeding not requiring medical intervention or further evaluation | Skin bruising, ecchymosis, self-resolving epistaxis, minimal conjunctival bleeding | Continue DAPT | Reassure the patient Identify preventive strategies Drug-adherence counselling |
| Mild | Any bleeding that requires medical attention without requiring hospitalization | Not self-resolving epistaxis, moderate conjunctival bleeding, GU or GI bleeding without significant blood loss, mild hemoptysis | Continue DAPT Consider shortening DAPT duration Consider DAPT de-escalation |
Identify and treat bleeding-related conditions Add PPI if not present Drug adherence counselling |
| Moderate | Any bleeding associated with a significant blood loss (>3 g/dL Hb) and/or requiring hospitalization, hemodynamically stable and not evolving | GU, respiratory or GI bleeding with significant blood loss or requiring blood transfusion | Consider switching from DAPT to SAPT Reinitiate DAPT as soon as deemed safe Consider DAPT de-escalation Consider shortening DAPT duration |
Identify and treat bleeding-related conditions i.v. PPI if GI bleeding Drug adherence counselling |
| Severe | Any bleeding requiring hospitalization, associated with a severe blood loss (>5 g/dL Hb), hemodynamically stable and not rapidly evolving | Severe GU, respiratory or GI bleeding. | Consider switching from DAPT to SAPT If bleeding persists despite treatment, consider stopping APT Re-evaluate need of APT once bleeding has ceased Consider shortening DAPT duration Consider DAPT de-escalation |
RBC if Hb < 7–8 g/dL Consider Plt transfusion Urgent treatment of bleeding source if possible i.v. PPI if GI bleeding |
| Life-threatening | Any severe active bleeding putting patient’s life immediately at risk | Massive overt GU, respiratory or GI bleeding, active intracranial, spinal or intraocular hemorrhage, or any bleeding causing hemodynamic instability | Immediately discontinue all APT Re-evaluate need of APT once bleeding has ceased. |
Fluid replacement RBC and Plt transfusion Urgent treatment of bleeding source if possible i.v. PPI if GI bleeding |