Chinese expert consensus on antithrombotic management of high‐risk elderly patients with chronic coronary syndrome

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TL;DR

This Chinese expert consensus provides guidance on antithrombotic therapy for elderly patients (≥65 years) with high-risk chronic coronary syndrome (CCS), emphasizing individualized assessment of ischemic and bleeding risks. It recommends dual antiplatelet therapy (DAPT) or dual pathway inhibition (DPI) with aspirin plus rivaroxaban 2.5 mg twice daily for patients with high ischemic risk and low bleeding risk, while single antiplatelet therapy is advised for those with high bleeding risk. The consensus also addresses management in patients with atrial fibrillation, venous thromboembolism, and perioperative settings, highlighting the importance of dynamic risk assessment and geriatric comprehensive evaluation.

Full summary

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**Background:** Coronary artery disease (CAD) prevalence and mortality are increasing in China. Chronic coronary syndrome (CCS) is the main manifestation in elderly patients, with high morbidity, long disease course, and poor prognosis. Antithrombotic therapy is crucial, but there is a lack of specific guidelines for elderly high-risk CCS patients. This consensus, developed by the Geriatrics Branch of the Chinese Medical Association, aims to standardize antithrombotic management in this population.

**Methods:** The consensus was developed by a panel of Chinese experts based on published clinical research evidence, combined with relevant guidelines, consensus, and expert recommendations from China and abroad. It defines elderly patients with high-risk CCS as those aged ≥65 years with high ischemic risk (cardiovascular mortality >3%/year) or high bleeding risk (major bleeding ≥4% or intracranial hemorrhage ≥1% at 1 year). High ischemic risk factors include advanced age (≥80 years), multi-vessel disease, multi-bed vascular disease, and comorbidities like diabetes, hypertension, and renal insufficiency. High bleeding risk factors include uncontrolled hypertension, anemia, thrombocytopenia, recent spontaneous bleeding, severe CKD, and prior intracranial hemorrhage.

**Key Results:** The consensus provides specific recommendations for antithrombotic therapy in various scenarios: - For elderly CCS patients with multi-vessel CAD and high ischemic risk without high bleeding risk, a second antithrombotic drug (P2Y12 receptor antagonist or rivaroxaban 2.5 mg twice daily) is recommended on top of aspirin 75–100 mg/day. For those with high bleeding risk, single antiplatelet therapy is recommended. - For patients undergoing elective PCI, DAPT duration is recommended as 6 months after DES implantation, with shorter durations (<6 months) for high bleeding risk and longer (>6 months) for high ischemic risk. For drug-coated balloons, DAPT may be reduced to 4 weeks. - For patients with peripheral artery disease (PAD), dual pathway inhibition (aspirin + rivaroxaban 2.5 mg twice daily) is recommended for secondary prevention (based on COMPASS study: HR 0.72, 95% CI 0.57–0.90 for primary efficacy endpoint). - For patients with prior stroke, rivaroxaban 2.5 mg twice daily + aspirin is recommended for those with low bleeding risk (at least 1 month after non-lacunar stroke). - For CCS patients with atrial fibrillation, oral anticoagulant (OAC) monotherapy is recommended based on CHA2DS2-VASc score. If high ischemic risk and low bleeding risk, aspirin may be added. NOACs are preferred over vitamin K antagonists. - For patients with venous thromboembolism (VTE), anticoagulation is foundational, with NOACs preferred for non-cancer-associated VTE. The course depends on whether VTE is provoked by a transient or chronic risk factor. - Bleeding risk assessment tools include PRECISE-DAPT score for antiplatelet therapy and HAS-BLED score for anticoagulant therapy. Geriatric comprehensive assessment is recommended, focusing on falls, polypharmacy, frailty, and dementia. - Management of bleeding includes specific guidance for intracerebral hemorrhage (discontinue antithrombotic therapy, blood pressure control), gastrointestinal bleeding (PPIs recommended, endoscopy within 24 hours), and anemia (restrictive transfusion strategy, Hb target <90 g/L). - Special populations: For renal dysfunction, dose adjustments for NOACs are recommended based on CrCl. For hepatic impairment, Child-Pugh classification guides drug selection. For advanced-age or frail patients, bleeding risks should guide optimization, and combination antiplatelet and anticoagulant therapy should be avoided if possible.

**Clinical Implications:** This consensus provides a comprehensive framework for antithrombotic management in elderly high-risk CCS patients, emphasizing the balance between ischemic and bleeding risks. It highlights the importance of individualized therapy based on risk stratification, dynamic assessment, and geriatric evaluation. The recommendations aim to maximize antithrombotic benefits while minimizing bleeding complications, ultimately improving outcomes in this vulnerable population.