What should be done with aspirin and clopidogrel (P2Y12 inhibitor) in a patient with a history of ST-Elevation Myocardial Infarction (STEMI) with stent placement, now admitted for an acute upper Gastrointestinal (GI) bleed?

From the Guidelines

In a patient with a history of STEMI with stent placement 6 weeks ago, now admitted for an acute upper GI bleed, aspirin should be continued while clopidogrel should be temporarily discontinued. This approach is based on the recommendation from the joint Asian Pacific Association of Gastroenterology (APAGE) and Asian Pacific Society for Digestive Endoscopy (APSDE) practice guidelines 1. The guidelines suggest that in patients on dual antiplatelet therapy (DAPT) with aspirin and clopidogrel, aspirin should be continued and clopidogrel withheld in acute non-variceal upper GI bleeding. The reasons for this recommendation include evidence that continuation of aspirin alone delays the onset of coronary events in patients on DAPT, and the potential interaction between proton-pump inhibitors (PPIs) and clopidogrel, particularly in slow metabolizers of CYP2C19, which may reduce the efficacy of clopidogrel 1. Key considerations in managing these patients include:

• The risk of stent thrombosis, which is higher in patients with acute coronary syndrome within 6 months, and the need for cardiology consultation before discontinuing antiplatelet therapy 1.
• The use of high-dose PPIs in the management of acute bleeding, which may interact with clopidogrel, particularly in slow metabolizers of CYP2C19 1.
• The potential for reversible P2Y12 receptor inhibitors like ticagrelor to be resumed sooner than irreversible inhibitors like clopidogrel and prasugrel after endoscopic hemostasis 1. Given the patient's recent stent placement and the need to balance bleeding and thrombotic risks, continuing aspirin while temporarily discontinuing clopidogrel appears to be the most appropriate approach, with close monitoring and cardiology consultation to determine the optimal timing for resuming clopidogrel 1.

From the FDA Drug Label

4.1 Active Bleeding Clopidogrel tablets are contraindicated in patients with active pathological bleeding such as peptic ulcer or intracranial hemorrhage.

5.2 General Risk of Bleeding P2Y12 inhibitors (thienopyridines), including clopidogrel, increase the risk of bleeding.

The patient has a history of STEMI with stent placement and is on aspirin and clopidogrel, now admitted for an acute upper GI bleed. Aspirin and clopidogrel should be stopped temporarily due to the active bleeding, as clopidogrel is contraindicated in patients with active pathological bleeding. However, the decision to stop these medications should be made in consultation with a cardiologist, considering the risk of cardiovascular events with discontinuation of clopidogrel.

• The patient's hemoglobin is stabilized after transfusion, but the risk of re-bleeding should be weighed against the risk of cardiovascular events.
• Aspirin may be restarted after the bleeding risk has decreased, but this decision should be made on a case-by-case basis.
• Clopidogrel should not be restarted until the bleeding risk has significantly decreased, and the patient is stable.
• Consider using proton pump inhibitors (PPIs) to reduce the risk of re-bleeding, but avoid using omeprazole or esomeprazole due to their interaction with clopidogrel 2.

From the Research

Management of Aspirin and Clopidogrel in a Patient with a History of STEMI and Acute Upper GI Bleed

• The patient has a history of ST-Elevation Myocardial Infarction (STEMI) with stent placement 6 weeks ago and is currently on aspirin and clopidogrel, presenting with an acute upper GI bleed requiring 2 units of packed red blood cell transfusion.
• The coagulation panel is normal, and endoscopy reveals a clean-based duodenal ulcer.

Considerations for Antiplatelet Therapy

• Dual antiplatelet therapy (aspirin and a P2Y12 antagonist) is required after the insertion of a coronary artery stent, especially in the context of an acute coronary syndrome (ACS) 3.
• The risk of gastrointestinal bleeding should be considered, and the use of a proton pump inhibitor (PPI) may be recommended for patients at high risk of GI bleed 3, 4.
• In patients with a history of STEMI and stent placement, the risk of stent thrombosis is a significant concern, and discontinuation of antiplatelet therapy (particularly clopidogrel) is a strong independent risk factor for stent thrombosis 5.

Recommendations for Aspirin and Clopidogrel Management

• For patients on cardiac acetylsalicylic acid (ASA) for secondary prevention, it is suggested to continue ASA, but if it has been interrupted, resumption is recommended on the day hemostasis is endoscopically confirmed 6.
• For patients on dual antiplatelet therapy for secondary prevention, temporary interruption of the P2Y12 receptor inhibitor (clopidogrel) may be considered while continuing ASA 6.
• Given the patient's recent GI bleed, the use of a PPI may be recommended to reduce the risk of further GI bleeding, but the choice of PPI should be considered to minimize potential interactions with clopidogrel 3, 4.

Clinical Decision

• Based on the available evidence, it is recommended to continue aspirin and consider temporarily interrupting clopidogrel (P2Y12 receptor inhibitor) in this patient with a history of STEMI and acute upper GI bleed 6.
• The use of a PPI, such as pantoprazole, may be recommended to reduce the risk of further GI bleeding, taking into account the potential interactions with clopidogrel 3, 4.