Table 3:

Management of bleeding events in patients with acute coronary syndrome receiving antithrombotic therapy

Bleeding event	Event description	Antithrombotic treatment modification
Bleeding event	Event description	Original treatment	Modification
Trivial bleeding	A bleeding event not requiring medical attention or further evaluation (e.g., skin bruising, self-resolving epistaxis, minimal conjunctival bleeding)	DAPT	Continue DAPT
Trivial bleeding		Concomitant OAC^*	Consider continuation of the regimen or skip a single dose of OAC
Mild bleeding	A bleeding event requiring medical attention without need for hospital admission (e.g., major epistaxis, moderate conjunctival bleeding, genitourinary or gastrointestinal bleeding without substantial blood loss, mild hemoptysis)	DAPT	Continue DAPT Consider shortening DAPT or de-escalation to a less potent P2Y₁₂ inhibitor
Mild bleeding		Concomitant OAC^*	In patients on VKA: consider holding drug until INR < 2 In patients on DOAC: skip a single dose In patients on TT: consider switching to dual therapy (clopidogrel and OAC)
Moderate bleeding	A bleeding event requiring hospital admission or associated with substantial blood loss (≥ 3 mmol/L hemoglobin) without hemodynamic instability (e.g., genitourinary, respiratory, upper or lower gastrointestinal bleeding with substantial blood loss or requiring transfusion)	DAPT	Consider stopping DAPT and continuing with a single P2Y₁₂ inhibitor Resume DAPT within 3 days if considered safe to do so Consider shortening DAPT or de-escalation to a less potent P2Y₁₂ inhibitor
Moderate bleeding		Concomitant OAC^*	Consider stopping OAC or reversing VKA with vitamin K (unless CHA₂DS₂-VASc ≥ 4 or a cardiac assist device or mechanical heart valve is present) If DOAC was taken within 2–4 hours, charcoal or dialysis (for patients on dabigatrtan) can be used Consider resuming treatment within 1 week, if patient is clinically stable In patients on VKA: consider a target INR 2.0–2.5 (unless mechanical heart valve or cardiac assist device is present) In patients on DOAC: consider the lowest effective dose In patients on TT: consider switching to dual therapy (clopidogrel and OAC)
Severe bleeding	A bleeding event associated with severe blood loss (≥ 5 mmol/L hemoglobin) in a hemodynamically unstable patient requiring hospital admission (e.g., severe genitourinary, respiratory or gastrointestinal bleeding, bleeding into critical spaces such as pericardium, retroperitoneum, intraocular spinal or intracranial spaces)	DAPT	Consider stopping DAPT and continue with SAPT (preferably with P2Y₁₂ inhibitor) Consider stopping all antithrombotic agents if bleeding persists Once bleeding has ceased, reassess the need for DAPT or SAPT; if DAPT is resumed, consider shortening length of treatment or de-escalating to a less potent P2Y₁₂ inhibitor
Severe bleeding		Concomitant OAC^*	Stop or reverse OAC until bleeding stops (except for patients with an extreme thrombotic risk, i.e., with a mechanical heart valve in mitral position or cardiac assist device) In patients on VKA: administer FFP or 4F-PCC In patients on DOAC: administer 4F-PPC In patients on dabigatran: consider administering idarucizumab Consider resuming treatment within 1 week, if clinically stable In patients on VKA: consider target INR of 2.0–2.5 (except for patients with mechanical heart valves and cardiac assist devices) In patients on DOAC: consider the lowest effective dose In patients on TT: consider switching to dual therapy (clopidogrel and OAC)
Life-threatening bleeding	Any severe active bleeding that poses a threat to a patient’s life (e.g., massive genitourinary, respiratory or gastrointestinal bleeding, active intracranial, spinal or intraocular hemorrhage, any bleeding causing hemodynamic instability)	DAPT	Stop all antithrombotic agents immediately Once bleeding has ceased, reassess the need for DAPT or SAPT, preferably with clopidogrel (particularly in patients who had upper GI bleeding)
Life-threatening bleeding		Concomitant OAC^*	Stop and reverse OAC In patients on VKA: use FFP or 4F-PCC In patients on dabigatran: consider administering idarucizumab

Note: 4F-PCC = 4-factor prothrombin complex concentrate, ACS = acute coronary syndrome, CHA₂DS₂-VASc = score that evaluates risk of ischemic stroke, DAPT = dual antiplatelet therapy, DOAC = direct oral anticoagulant, FFP = fresh frozen plasma, GI = gastrointestinal, INR = international normalized ratio, OAC = oral anticoagulant, SAPT = single antiplatelet therapy, TT = triple therapy, VKA = vitamin K antagonist.
↵* Concomitant OAC with antiplatelet therapy, including both SAPT and DAPT.