University of Hertfordshire

From the same journal

By the same authors

  • Bhatt Deepak
  • Juan Carlos Kaski
  • Sean Delaney
  • Mirvat Alasnag
  • Felicita Andreotti
  • Dominick J. Angiolillo
  • Albert Ferro
  • Diana Gorog
  • Alberto Lorenzatti
  • Mamas A. Mamas
  • John McNeil
  • José C Nicolau
  • Gabriel Philippe Steg
  • Juan Tamargo
  • Tan Doreen
  • Marco Valgimigli
View graph of relations
Original languageEnglish
JournalInternational Journal of Cardiology
Publication statusAccepted/In press - 5 May 2021


Aims. Choosing an antiplatelet strategy in patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS) at high bleeding risk (HBR), undergoing post-percutaneous coronary intervention (PCI), is complex. We used a unique open-source approach (crowdsourcing) to document if practices varied across a small, global cross-section of antiplatelet prescribers in the post-PCI setting. Methods and Results. Five-hundred and fifty-nine professionals from 70 countries (the ‘crowd’) completed questionnaires containing single- or multi-option and free form questions regarding antiplatelet clinical practice in post-PCI NSTE-ACS patients at HBR. A threshold of 75% defined ‘agreement’. There was strong agreement favouring monotherapy with either aspirin or a P2Y12 inhibitor following initial DAPT, within the first year (94%). No agreement was reached on the optimal duration of DAPT or choice of monotherapy: responses were in equipoise for shorter (<3 months, 51%) or longer (>6 months, 46%) duration, and monotherapy choice (45% aspirin; 53% P2Y12 inhibitor). Most respondents stated use of guideline-directed tools to assess risk, although clinical judgement was preferred by 32% for assessing bleeding risk and by 46% for thrombotic risk. Conclusion. The crowdsourcing methodology showed potential as a tool to assess current practice and variation on a global scale and to achieve a broad demographic representation. These preliminary results indicate a high degree of variation with respect to duration of DAPT, monotherapy drug of choice following DAPT and how thrombotic and bleeding risk are assessed. Further investigations should concentrate on interrogating practice variation between key demographic groups. Keywords Antiplatelet therapy; crowdsourcing; high bleeding risk; non-ST segment elevation acute coronary syndrome; P2Y12 receptor inhibitors; percutaneous coronary intervention   Highlights • Antiplatelet choice is complex in NSTE-ACS patients at high bleeding risk • Practice is expected to vary and may deviate from guidelines • A crowdsourcing approach was used to assess current practices • We noted high practice variation across a global cohort of prescribers • Crowdsourcing may be an effective tool to monitor practice variation 1.0 Introduction In patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS) at high bleeding risk (HBR), current guidelines recommend short duration of dual antiplatelet therapy (DAPT) with aspirin (ASA) and the P2Y12 inhibitor clopidogrel, followed by monotherapy with ASA thereafter, in the post percutaneous coronary intervention (PCI) setting.1,2 Randomised data from the CAPRIE trial, however, show that clopidogrel monotherapy reduces hospitalisation for gastrointestinal bleeding compared with ASA 325 mg daily, and that gastrointestinal bleeding is the most prevalent bleeding occurrence after PCI in the outpatient setting.3 In addition, since the publication of the most recent set of guidelines (ESC in 2020), at least two independent meta-analyses suggest that discontinuing ASA and continuing P2Y12 inhibitor monotherapy after short duration DAPT, provides additional protection against bleeding, without increasing thrombotic risk.4,5 The choice of antiplatelet strategy in the HBR population is therefore complicated and despite growing evidence supporting the use of P2Y12 monotherapy following initial DAPT,4–11 it is reasonable to expect that practice may vary. To gain insight into current practices and variation with respect to antiplatelet therapy, we solicited input from a global audience of cardiology professionals. Given the inherent selectivity of more traditional survey methods, where participants are often predetermined, we utilised an open-source approach, driven primarily through social media. This novel ‘crowdsourcing’ methodology was chosen for its potential to reach a broad audience of antiplatelet prescribers. Here, we describe the findings of this preliminary study with respect to adherence to guideline-directed care in NSTE-ACS patients at HBR, post-PCI, from a small, global cohort of professionals.


© 2021 The Author(s). Published by Elsevier B.V.

ID: 25181535