High Bleeding Risk Patients Undergoing Percutaneous Coronary Intervention: How to Choose the Optimal Antithrombotic Therapy, Its Duration and the Right Stent; A Comprehensive Review of the Current Literature and Proposed Treatment Algorithms

High bleeding risk (HBR) patients represent a significant proportion of those who undergo percutaneous coronary interventions (PCI). The accurate diagnosis of the HBR population is essential because they suffer significantly higher rates of mortality and bleeding compared with non-HBR patients. Although many bleeding risk scores have been developed, the Academic Research Consortium for HBR (ARC–HBR) criteria have established their superiority over the others. In HBR patients without an indication for oral anticoagulant (OAC), shortening the duration of dual antiplatelet therapy (DAPT) is an effective way to minimize bleeding complications in HBR patients with chronic coronary syndromes (CCS). In cases of an acute coronary syndrome (ACS) however, HBR patients combine increased thrombotic burden with an augmented risk of bleeding. Early antiplatelet interruption could result in stent thrombosis with catastrophic consequences. Therefore, in HBR patients with an ACS choosing the optimal DAPT duration, the right P2Y12 inhibitor and the correct time for de-escalation from a potent P2Y12 inhibitor to clopidogrel are of paramount importance. Similar considerations apply to patients with an OAC indication who, according to the ARC–HBR criteria, are HBR. Although new-generation drug-eluting stents (DES) have been developed to induce faster stent endothelization, only few DES have been examined in a HBR population, and these stents should be preferred. The aim of this review is to present the current knowledge of the HBR population and provide comprehensive algorithms to optimally treat HBR patients who undergo PCI with or without an OAC indication and for both ACS and CCS.