p.59 抽出テキスト

CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2025;151:e771–e862. DOI: 10.1161/CIR.0000000000001309 April 1, 2025 e829

additional months).21 In the absence of oral anticoagulant use, the choice of discontinuing aspirin or P2Y12 inhibitor and the choice of P2Y12 inhibitor was at the discretion of the treating physician. An oral anticoagulant was used in 36.4% of patients, and clopidogrel monotherapy was selected in 53.9% of patients randomized to abbreviated DAPT. Compared with standard therapy, an abbreviated antiplatelet strategy demonstrated noninferiority with respect to composite ischemic events and superiority regarding clinically relevant bleeding over 1 year. Among patients with ACS (n=1780; 30% STEMI) allocated to an abbreviated strategy, clinicians selected a potent P2Y12 inhibitor with ticagrelor use in approximately 25% of patients.56 Results in the ACS cohort were qualitatively consistent with the overall trial results with respect to both ischemic and bleeding outcomes. Although the trial demonstrated noninferiority for abbreviated DAPT with respect to MACE in patients at high bleeding risk, it was underpowered to determine the relative safety of discontinuing aspirin versus P2Y12 inhibitor. Multiple studies have identified clinical and laboratory predictors of bleeding and/or ischemic risk.24–27 The Academic Research Consortium determined 20 correlates of bleeding and proposed a consensus-based definition of high bleeding risk as the presence of having at least 1 major or 2 minor criteria at time of PCI (Table 22).26 11.1.1 Antiplatelet Therapy in Patients on Anticoagulation Postdischarge

Recommendation for Antiplatelet Therapy in Patients on Anticoagulation Postdischarge Referenced studies that support recommendation are summarized in the Evidence Table.

COR LOE Recommendation

1 B-R 1 In patients with ACS who require oral

anticoagulant therapy, aspirin should be discontinued after 1 to 4 weeks of triple antithrombotic therapy, with continued use of a P2Y12 inhibitor (preferably clopidogrel) and an oral anticoagulant to reduce bleeding risk.*1–5

*Modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”6

Synopsis Patients after ACS may frequently have indications for anticoagulant therapy, including AF, venous thromboembolism, and prosthetic heart valves. Bleeding risks are increased in the setting of triple therapy with the combination of aspirin, P2Y12 inhibitor, and anticoagulant. Therefore, the benefits of these therapies must be weighed against the risk of bleeding. A growing number of studies have demonstrated the overall safety of a strategy of aspirin discontinuation 1 to 4 weeks after ACS or PCI in patients who require anticoagulation after ACS.1–5 For most patients, a DOAC will be preferred over a vitamin K antagonist due to their favorable efficacy and safety profile.7 Trials of more potent P2Y12 inhibitors

Table 22.  Academic Research Consortium High Bleeding Risk Criteria After PCI Major Criteria26 Minor Criteria

Age ≥75 y

Anticipated use of long-term oral anticoagulation (Section 11.1.1, “Antiplatelet Therapy in Patients on Anticoagulation Postdischarge”) Severe or end-stage CKD (eGFR <30 mL/min) Moderate CKD (eGFR 30-59 mL/min) Hemoglobin level <11 g/dL Hemoglobin level 11-12.9 g/dL for men and 11-11.9 g/dL for women Spontaneous bleeding requiring hospitalization or transfusion in the past 6 mo or at any time, if recurrent Spontaneous bleeding requiring hospitalization or transfusion within the past 12 mo not meeting the major criterion Moderate or severe baseline thrombocytopenia (platelet count <100×109/L) Chronic bleeding diathesis Liver cirrhosis with portal hypertension

Long-term use of oral NSAIDs or steroids

Active malignancy (excluding nonmelanoma skin cancer) within the past 12 mo Previous spontaneous ICH (at any time) Previous traumatic ICH within the past 12 mo Presence of a brain arteriovenous malformation Moderate or severe ischemic stroke within the past 6 mo Any ischemic stroke at any time not meeting the major criterion Nondeferrable major surgery on DAPT Recent major surgery or major trauma within 30 d before PCI The presence of at least 1 major or 2 minor criteria helps to identify those at increased risk of bleeding. Modified with permission from Urban et al.26 Copyright 2019 American Heart Association, Inc. CKD indicates chronic kidney disease; DAPT, dual antiplatelet therapy; eGFR, estimated glomerular filtration rate; NSAID, nonsteroidal anti-inflammatory drugs; ICH, intracranial hemorrhage; and PCI, percutaneous coronary intervention.

Downloaded from http://ahajournals.org by on October 7, 2026