Abstrakt
A Cornelian dilemma (dilemme Corneillian) is a dilemma in which someone is obliged to choose one option from a range of options, all of which reveal a detrimental effect on themselves or someone near them. In contrast to primary prevention the status of aspirin in the treatment of vascular diseases caused by atherothrombosis is unquestionable and unshakable.
In addition to its undeniable efficiency, its affordability is a significant extra benefit. However, preventing thrombosis after iatrogenic disruption of the inner surface of a vessel wall by implantation of an intracoronary stent needs more than the antithrombotic efficacy of aspirin.
The TWILIGHT trial tested the safety of DAPT de-escalation to ticagrelor monotherapy starting after an adverse event-free 3 month period following PCI in patients at high thrombotic and/or bleeding risk according to a list of clinical and angiographic criteria. Patients on oral anticoagulation, with a platelet count <100 000 mm3, on dialysis, with a prior stroke, or with an 'extreme risk' for major bleeding, as well as those undergoing primary or salvage PCI were excluded, representing, however, the most serious potential bleeders in whom the management is the most difficult.
In this issue of the European Heart Journal published the TWILIGHT-HBR pre-specified subgroup analysis of patients with at least a 4% risk of BARC bleeding 3 (= overt bleeding plus hemoglobin drop at least 3 g per dL, or cardiac tamponade, or intraocular bleed compromising vision, or need of any transfusion, intravenous vasoactive agents, surgical intervention to stop bleeding) or 5 (fatal bleeding) or at least a 1% risk of intracranial bleeding within 12 months after the index PCI is adding consistency in the challenge of selecting an antiplatelet therapy strategy in patients well defined for their HBR.