The balance between anti-ischemic efficacy and bleeding risk of antithrombotic therapy in percutaneous coronary intervention: a Yin-Yang paradigm.

BACKGROUND: The development of newer and more potent antithrombotic agents and strategies has markedly reduced cardiovascular mortality and ischemic complications in patients with acute coronary syndromes and those undergoing percutaneous coronary intervention (PCI). With every approach to reduce coronary thrombosis, however, there is an accompanying risk of increasing bleeding complications elsewhere. Conversely, reducing bleeding complications may increase coronary thrombotic (ischemic) events. This is the Yin-Yang principle of antithrombotic therapy and strategies in PCI. Balancing both ends of the spectrum is essential, and an individualized approach to therapy is advocated. This article reviews the efficacy and bleeding risk profile of the different antithrombotic agents and strategies in PCI, including aspirin, thienopyridines, glycoprotein IIb/IIIa-inhibitors, heparin-based antithrombins, synthetic antithrombins and oral anticoagulants. Recommendations for reducing thrombotic and bleeding complications are also discussed.