What is the most appropriate oral antithrombotic regimen for a 76-year-old female with a history of chronic stable angina, recent gastrointestinal bleeding, and uncontrolled hypertension, currently taking clopidogrel (Plavix) and aspirin (acetylsalicylic acid)?

From the Guidelines

The most appropriate oral antithrombotic regimen for TJ at hospital discharge would be to stop clopidogrel and continue aspirin 81 mg orally daily. This recommendation is based on several important clinical factors in her case. TJ has experienced gastrointestinal bleeding while on dual antiplatelet therapy (DAPT) with aspirin and clopidogrel, which significantly increases her risk for recurrent bleeding events. Since she is 9 months post drug-eluting stent placement, she has already completed the highest risk period for stent thrombosis, which typically requires 6-12 months of DAPT, as suggested by the 2024 ESC guidelines for the management of chronic coronary syndromes 1. At this point, the bleeding risk from continued DAPT outweighs the thrombotic risk. Continuing a single antiplatelet agent with low-dose aspirin provides some protection against stent thrombosis while reducing bleeding risk.

Some key points to consider in this decision include:

• The patient's history of gastrointestinal bleeding, which increases the risk of further bleeding events
• The timing of the drug-eluting stent placement, which suggests that the highest risk period for stent thrombosis has passed
• The importance of balancing the risk of bleeding against the risk of thrombotic events
• The role of aspirin in providing ongoing protection against stent thrombosis while minimizing bleeding risk

Additionally, her use of meloxicam (an NSAID) likely contributed to her GI bleeding risk, and this medication should be reevaluated. The pantoprazole should be continued for gastric protection. Alternative options like rivaroxaban or ticagrelor would not be appropriate as they would maintain or potentially increase her bleeding risk without providing clear benefit over the recommended approach in her specific clinical scenario, as indicated by the 2020 ACC expert consensus decision pathway for anticoagulant and antiplatelet therapy in patients with atrial fibrillation or venous thromboembolism undergoing percutaneous coronary intervention or with atherosclerotic cardiovascular disease 1.

From the FDA Drug Label

5.3 Discontinuation of Clopidogrel Discontinuation of clopidogrel increases the risk of cardiovascular events. If clopidogrel must be temporarily discontinued (e.g., to treat bleeding or for surgery with a major risk of bleeding), restart it as soon as possible. When possible, interrupt therapy with clopidogrel for five days prior to such surgery. Resume clopidogrel as soon as hemostasis is achieved.

The most appropriate oral antithrombotic regimen for TJ at the time of hospital discharge is to continue clopidogrel and aspirin. This is because discontinuation of clopidogrel increases the risk of cardiovascular events, and TJ has a history of coronary artery disease with a drug-eluting stent placement 9 months ago. Although TJ presented with gastrointestinal bleeding, the benefits of continuing clopidogrel and aspirin likely outweigh the risks in this case. TJ is already taking pantoprazole, which may help reduce the risk of further gastrointestinal bleeding. 2

From the Research

Oral Antithrombotic Regimen for TJ

Given TJ's past medical history and current presentation, the most appropriate oral antithrombotic regimen at the time of hospital discharge must balance the risk of gastrointestinal bleeding with the need to prevent cardiovascular events.

• TJ has a history of chronic stable angina, peptic ulcer disease, osteoarthritis, and uncontrolled hypertension, and she recently presented with gastrointestinal bleeding.
• She is currently on amlodipine, pantoprazole, atorvastatin, metoprolol tartrate, meloxicam, clopidogrel, and aspirin.
• The use of proton pump inhibitors (PPIs) like pantoprazole with clopidogrel may decrease the antiplatelet effects of clopidogrel, potentially increasing the risk of cardiovascular events 3, 4.
• However, PPIs are also recommended to reduce the risk of gastrointestinal bleeding in patients on antiplatelet therapy, especially those with a history of gastrointestinal bleeding 5, 6.
• Aspirin and clopidogrel are commonly used antiplatelet agents, but they increase the risk of gastrointestinal bleeding, particularly when used together 7, 5.

Considerations for TJ’s Regimen

Considering TJ's recent gastrointestinal bleeding and her history of peptic ulcer disease, the risk of further bleeding must be carefully weighed against the risk of cardiovascular events.

• Stopping clopidogrel and continuing aspirin 81 mg orally daily could reduce the risk of gastrointestinal bleeding but may not provide sufficient protection against cardiovascular events.
• Stopping both clopidogrel and aspirin and starting rivaroxaban or ticagrelor would significantly alter her antithrombotic regimen, and there is limited direct evidence to support this approach in her specific clinical scenario.
• Continuing both clopidogrel and aspirin would maintain her current level of antiplatelet therapy but may increase her risk of further gastrointestinal bleeding.

Most Appropriate Regimen

Given the information available and the need to balance the risks of gastrointestinal bleeding and cardiovascular events, the most appropriate decision would be to continue clopidogrel and aspirin, as this maintains her protection against cardiovascular events while acknowledging the potential increased risk of gastrointestinal bleeding 3, 4, 5, 6. However, it is crucial to closely monitor her for signs of bleeding and adjust her regimen as necessary, potentially including the use of PPIs to mitigate gastrointestinal risk.