Conversion And Outcome Of Dual Antiplatelet Therapy After Bleeding In Patients With Acute Coronary Syndrome

Objective:The purpose of this study was to study the risk factors for bleeding and explore the conversion and outcome of antiplatelet therapy in patients with acute coronary syndrome(ACS)who have suffered bleeding after receiving aspirin combined with ticagrelor.Methods:Patients who diagnosed with ACS at the First Affiliated Hospital of Dalian Medical University and given aspirin 100 mg once daily combined with ticagrelor 90 mg twice daily for dual antiplatelet therapy(DAPT)were selected.The patients were divided into bleeding group and non-bleeding group according to whether bleeding events occurred within one year after DAPT.The bleeding group was divided into the next four groups according to the converted antiplatelet treatment strategy decided by the doctor,Patients in group A to D were treated with ticagrelor 90mg twice a day plus aspirin 0-50mg once a day,ticagrelor 45-60mg twice a day plus aspirin 100mgonce a day,clopidogrel 75mgonce a day plus aspirin 100mg once a day and ticagrelor 90mg twice a day plus aspirin 100mg once a day,respectively.All of the patient were followed up until 1 year after DAPT.The primary outcome is bleeding degree by BARC.The secondary outcomes includes all-cause mortality,MACE(cardiac death,myocardial infarction,unstable angina pectoris,heart failure,revascularization,stent thrombosis and new cerebral infarction).Results:A total of 752 cases were enrolled,including 250 in the bleeding group and 502 in the non-bleeding group.The incidence of BARC bleeding events was 33.24%,3 cases of BARC type 5 fatal hemorrhage,0.40%of fatal hemorrhage,and bleeding mostly occurs within 3 months.Spearman correlation test suggests that bleeding is related to age,gender,weight,hypertension,smoking history,renal function,and anemia.The result of multivariate logistic regression analysis showed that female(OR=5.18,95%CI=1.61-16.65,P<0.01),low body weight(OR=7.73,95%CI=2.46-24.49,P<0.01)and low AA-induced maximum platelet aggregation rate(OR=2.72,95%CI=1.09-6.84,P=0.03)were independent risk factors for hemorrhage.All of the 250 patients in the bleeding group,3 were of BARC5 type,3 of them discontinued the antiplatelet drug without their doctor’s advice,5 people adopted a strategy that does not meet the enrollment plan,a total of 11 patients were excluded.bleeding group was divided into four treatment groups,which were 63 cases,43 cases,38 cases,and 95 cases among A,B,C and D group.There was a significant difference in the improvement of bleeding among the four groups.To be noted,patients in group A has the highest improvement rate of hemorrhage(65.1%vs 62.8%vs 47.4%vs 24.2%,P<0.01).There were no significant differences in the incidence of MACE(P>0.05).Conclusion:1.Patients receiving aspirin combined with ticagrelor had a high incidence of BARC bleeding events,but most of them were the BARC1 type,and bleeding mostly occurs within 3 months.Clinicians need to strengthen the follow-up at the beginning of DAPT and pay attention to small bleeding events,and improve patient medication compliance.2.Female,low body mass and low AA-induced maximum platelet aggregation rate are independent risk factors for bleeding.3.After a non-fatal bleeding event in ACS patients receiving aspirin combined with ticagrelor double antiplatelet therapy,choose a reduced-order treatment strategy such as reducing aspirin dose,reducing ticagrelor dose,and replacing ticagrelor with clopidogrel,Can effectively improve bleeding without increasing the risk of ischemia.