From the Guidelines
The primary recommendation is to temporarily discontinue clopidogrel while continuing low-dose aspirin, and urgently investigate the source of gastrointestinal bleeding. Specific steps:
- Stop clopidogrel immediately
- Continue aspirin 81 mg daily
- Perform urgent colonoscopy within 24-48 hours to identify and potentially treat the bleeding source
- Provide supportive care including IV fluids and blood transfusion if needed based on hemoglobin levels and symptoms Once the bleeding is controlled and source identified:
- If low-risk lesion found (e.g., diverticular bleed): Resume clopidogrel after 1-3 days
- If high-risk lesion found (e.g., large polyp, cancer): Consult with cardiology about the possibility of switching to aspirin monotherapy Justification: The patient is at high risk for stent thrombosis due to recent PCI, necessitating continued antiplatelet therapy. Aspirin is maintained as it has a better benefit-to-risk ratio compared to clopidogrel in this scenario, as supported by the 2017 ESC guidelines for the management of acute myocardial infarction 1. Temporary discontinuation of clopidogrel allows for bleeding control while minimizing thrombotic risk. Prompt investigation is crucial to allow timely reinstitution of dual antiplatelet therapy if possible, balancing the risks of bleeding and stent thrombosis. The use of a proton pump inhibitor (PPI) in combination with dual antiplatelet therapy (DAPT) is recommended in patients at high risk of gastrointestinal bleeding, as stated in the 2017 ESC guidelines 1. However, the 2010 ACCF/ACG/AHA expert consensus document on the concomitant use of proton pump inhibitors and thienopyridines suggests that the routine use of PPIs is not recommended for patients at lower risk of upper GI bleeding 1.
Key considerations:
- The patient's history of myocardial infarction and recent PCI with a drug-eluting stent necessitates careful management of antiplatelet therapy to balance the risks of bleeding and stent thrombosis.
- The 2011 ACCF/AHA focused update incorporated into the ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction provides guidance on the use of antiplatelet therapy in patients with a history of gastrointestinal bleeding 1.
- The patient's current presentation with lower gastrointestinal bleeding requires urgent investigation and management to control the bleeding and prevent further complications.
From the FDA Drug Label
Bleeding CURE In CURE, clopidogrel use with aspirin was associated with an increase in major bleeding (primarily gastrointestinal and at puncture sites) compared to placebo with aspirin The overall incidence of bleeding is described in Table 1. Table 1: CURE Incidence of Bleeding Complications (% patients) EventClopidogrel (+ aspirin) (n=6259) Placebo (+ aspirin) (n=6303)
- Life-threatening and other major bleeding. †Led to interruption of study medication. Major bleeding* 3. 7 2.7 Life-threatening bleeding 2.2 1.8 Fatal 0.2 0.2 5 g/dL hemoglobin drop 0.9 0.9 Requiring surgical intervention 0.7 0.7 Hemorrhagic strokes 0.1 0.1 Requiring inotropes 0.5 0.5 Requiring transfusion (≥4 units) 1.2 1 Other major bleeding 1.6 1 Significantly disabling 0.4 0.3 Intraocular bleeding with significant loss of vision 0.05 0.03 Requiring 2 to 3 units of blood 1.3 0.9 Minor bleeding † 5. 1 2. 4
The patient should be managed by discontinuing Clopidogrel and Aspirin if possible, as they increase the risk of major bleeding, including gastrointestinal bleeding. The patient's current presentation of lower gastrointestinal bleeding may be related to the use of these medications. It is essential to monitor the patient's condition and manage the bleeding according to standard medical practices.
- Key considerations:
- Discontinue antiplatelet therapy if possible
- Monitor the patient's condition closely
- Manage the bleeding according to standard medical practices
- Consider alternative treatments for the patient's condition, if necessary 2
From the Research
Initial Assessment and Management
- The initial assessment of the 63-year-old man with a history of myocardial infarction (MI) and presenting with lower gastrointestinal bleeding should include a history of co-morbidities and medications that promote bleeding, hemodynamic parameters, physical examination, and laboratory markers 3.
- A risk score can be used to aid in decision-making, but should not replace clinician judgment 3.
- Given the patient's history of cardiovascular disease, a more liberal red blood cell transfusion strategy may be considered, with a hemoglobin threshold of ≤8 g/dL prompting red blood cell transfusion 3.
Medication Management
- Aspirin should not be withheld in patients taking low-dose aspirin for secondary cardiovascular prevention, and if withheld, should be resumed within 5 days or earlier if hemostasis is achieved or there is no further evidence of bleeding 3.
- Dual antiplatelet therapy (low-dose aspirin and a P2Y12 receptor antagonist) should not be routinely discontinued before cardiology consultation, and continuation of aspirin is recommended, whereas the P2Y12 receptor antagonist can be continued or temporarily interrupted according to the severity of bleeding and the ischemic risk 3.
Diagnostic and Therapeutic Modalities
- Colonoscopy is the diagnostic and therapeutic procedure of choice for acute and chronic lower gastrointestinal bleeding 4, 5.
- Computed tomography angiography may be used to diagnose the source of bleeding and guide management when embolization is indicated, especially in patients with severe bleeding and hemodynamic instability 6.
- Angiography and radioisotope scans may be used if colonoscopy fails or cannot be performed 5.