Reversal and removal of oral antithrombotic drugs in patients with active or perceived imminent bleeding

Remarkable progress has been made in the pharmacological management of patients with cardiovascular disease, including the frequent use of antithrombotic agents. Nonetheless, bleeding complications remain frequent and potentially life-threatening. Therapeutic interventions relying on prompt antithrombotic drug reversal or removal have been developed to assist clinicians in treating patients with active bleeding or an imminent threat of major bleeding due to urgent surgery or invasive procedures. Early phase studies on these novel strategies have shown promising results using surrogate pharmacodynamic endpoints. However, the benefit of reversing/removing antiplatelet or anticoagulant drugs should always be weighed against the possible prothrombotic effects associated with withdrawal of antithrombotic protection, bleeding, and surgical trauma. Understanding the ischemic-bleeding risk tradeoff of antithrombotic drug reversal and removal strategies in the context of urgent high-risk settings requires dedicated clinical investigations, but challenges in trial design remain, with relevant practical, financial, and ethical implications.

Automated summary

Significant progress has been made in the pharmacological management of cardiovascular disease, but bleeding complications remain common. Therapeutic interventions for antithrombotic drug reversal or removal have shown promising results but require careful consideration of the potential prothrombotic effects and risks associated with withdrawal of antithrombotic protection. There is a need for dedicated clinical investigations to understand the risk tradeoff in urgent high-risk settings, but challenges in trial design exist with practical, financial, and ethical implications.