Reassessing PCI Timing in High Bleeding Risk Patients: Evidence, Strategies, and Outcomes

Percutaneous coronary intervention (PCI) in patients with high bleeding risk (HBR) presents a therapeutic challenge, requiring careful balancing of ischemic prevention and bleeding avoidance. The Academic Research Consortium High Bleeding Risk (ARC-HBR) criteria provide a standardized framework for identifying this population, yet optimal PCI timing, procedural strategies, and antithrombotic regimens remain uncertain. This review synthesizes data from randomized controlled trials, large-scale registries, and meta-analyses involving HBR patients undergoing PCI in settings including stable coronary artery disease, acute coronary syndromes (ACS), ST-elevation myocardial infarction (STEMI), post-resuscitation states, and malignancy-related thrombocytopenia. Special emphasis is placed on procedural approaches (radial vs. femoral access), device selection (drug-coated balloons, polymer-free drug-eluting stents), and dual antiplatelet therapy (DAPT) duration. Evidence supports the safety of abbreviated DAPT regimens (1-3 months) when combined with bleeding-sparing techniques and devices, with the greatest benefit observed in patients with a high ischemic burden (e.g., GRACE score > 140). Early invasive management in ACS has been associated with reduced ischemic endpoints and shorter hospital stays without a significant rise in major bleeding. Conversely, delayed PCI is advisable in the presence of active bleeding, recent thrombolysis, or severe coagulopathy. Persistent limitations include underrepresentation of ARC-HBR patients in trials and lack of standardized, bleeding risk-tailored timing protocols. PCI in HBR patients can be performed safely and effectively when guided by individualized, evidence-based strategies for procedural timing and antithrombotic therapy. Future directions include integrating biomarker-driven DAPT modulation and artificial intelligence-based decision frameworks to optimize outcomes in this high-risk group.