How to manage a patient with a gastrointestinal (GI) bleed who has had a non-ST elevation myocardial infarction (NSTEMI) and stent placement less than 30 days ago, and is on dual antiplatelet therapy (DAPT)?

From the Guidelines

When managing a patient with a GI bleed who has had an NSTEMI with stent placement less than 30 days ago, it is recommended to temporarily discontinue the P2Y12 inhibitor while maintaining aspirin therapy, and restart the P2Y12 inhibitor as soon as possible after the GI bleed is controlled, ideally within 3-7 days, as supported by the most recent guidelines 1. The goal is to balance the risk of bleeding with the risk of stent thrombosis, which is highest within the first 30 days post-stent placement.

• Continue aspirin 81mg daily without interruption, as it provides essential protection against stent thrombosis.
• Hold the P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) until the GI bleed is controlled.
• Perform urgent endoscopy within 24 hours to identify and treat the bleeding source.
• Initiate proton pump inhibitor therapy (e.g., pantoprazole 40mg IV twice daily, transitioning to oral) immediately.
• Consider blood transfusion for hemoglobin levels below 7-8 g/dL.
• Collaborative management with cardiology and gastroenterology consultation is essential. This approach is supported by the 2018 European Society of Cardiology guidelines, which recommend DAPT for 12 months after PCI, unless there are contraindications such as excessive risk of bleeding 1. In patients at high risk of gastrointestinal bleeding, a PPI in combination with DAPT is recommended 1. The temporary discontinuation of one antiplatelet agent represents a compromise that minimizes bleeding while providing some protection against thrombotic complications.

From the Research

Management of GI Bleed in Patients with Recent NSTEMI and Stent Placement

• The management of a patient with a gastrointestinal (GI) bleed who has had a non-ST elevation myocardial infarction (NSTEMI) and stent placement less than 30 days ago, and is on dual antiplatelet therapy (DAPT), requires balancing the risk of stent thrombosis against further catastrophic bleeding 2.
• Close combined management between gastroenterologist and cardiologist is advocated to optimize patient outcomes 2.
• Discontinuation of antiplatelet therapy (particularly clopidogrel) is the strongest independent risk factor for the development of stent thrombosis 3.

Risk Factors for GI Bleeding

• Advanced age, a history of peptic ulcer disease, co-administration of non-steroidal anti-inflammatory drugs, co-administration of anticoagulants, and physiological stress are considered to be the major risk factors for GI bleeding in patients undergoing antiplatelet therapy following percutaneous coronary intervention (PCI) 4.
• The association of aspirin with the increased risk of upper GI bleeding has been well established, and peptic ulcer bleeding and Helicobacter pylori infection are the 2 most important risk factors for aspirin-associated GI bleeding complications 3.

Prevention and Treatment of GI Bleeding

• Endoscopy (for both surveillance and potential intervention) is the primary tool for definitive management of GI bleeding 3.
• Considering the increase in GI bleeding risk seen with prolonged antiplatelet therapy, adjunctive proton pump inhibitor therapy and/or eradication of H. pylori infection might be beneficial for patients on long-term antiplatelet therapy 3.
• The prevalence of GI bleeding in patients who are administered dual antiplatelet therapy following PCI is approximately 2%, and GI bleeding after PCI is associated with increased morbidity, mortality, duration of hospitalization and cost 4.

Decision to Stop DAPT

• There are no clear guidelines on when to stop DAPT in a patient with a GI bleed who has had a recent NSTEMI and stent placement, and the decision should be made on a case-by-case basis, taking into account the individual patient's risk factors and clinical presentation 2, 3.
• The risk of stent thrombosis must be weighed against the risk of further bleeding, and a multidisciplinary approach involving cardiologists and gastroenterologists is recommended to optimize patient outcomes 2, 3.