What antiplatelet therapy adjustments are recommended for a patient with a recent myocardial infarction (MI) and stent placement, who develops a duodenal ulcer and acute upper gastrointestinal (GI) bleeding, while on aspirin and clopidogrel?

From the Guidelines

For a patient with recent MI and stent placement who develops duodenal ulcer with acute upper GI bleeding while on dual antiplatelet therapy (DAPT), continuation of aspirin and clopidogrel is recommended, with the addition of a proton pump inhibitor (PPI) to reduce the risk of rebleeding, as the benefits of DAPT in preventing major adverse cardiac events (MACE) outweigh the risks of bleeding, according to the most recent guidelines 1. The patient's recent history of ST segment elevation myocardial infarction and drug-eluting stent placement indicates a high risk of stent thrombosis if antiplatelet therapy is discontinued prematurely.

• The risk of stent thrombosis is particularly high in the first few months after stent placement, with a mortality rate of 20-40% if antiplatelet therapy is discontinued prematurely.
• The 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline recommends that DAPT with aspirin and an oral P2Y12 inhibitor should be administered for at least 1 year to reduce MACE in patients with ACS who are not at high bleeding risk 1.
• In patients at high risk of gastrointestinal bleeding, a proton pump inhibitor (PPI) is recommended in combination with DAPT to reduce the risk of bleeding 1.
• Given the patient's history of acute upper GI bleeding, the addition of a PPI such as pantoprazole 40 mg daily or omeprazole 20 mg daily is recommended to reduce the risk of rebleeding.
• The PPI should be administered at a different time than clopidogrel to minimize potential interaction. This approach balances the competing risks of recurrent bleeding against potentially catastrophic stent thrombosis, and is supported by the most recent guidelines 1.

From the FDA Drug Label

The use of oral anticoagulants, nonstudy antiplatelet drugs, and chronic NSAIDs was not allowed in CURE. CYP2C19 inhibitors: Avoid concomitant use of omeprazole or esomeprazole. (5.1) Bleeding: Clopidogrel increases risk of bleeding. (5. 2) Discontinuation: Premature discontinuation increases risk of cardiovascular events. Discontinue 5 days prior to elective surgery that has a major risk of bleeding. ( 5.3)

The patient has a recent myocardial infarction and stent placement, and has developed a duodenal ulcer and acute upper gastrointestinal bleeding while on aspirin and clopidogrel.

• Continuation of antiplatelet therapy is crucial in patients with a recent myocardial infarction and stent placement to prevent further cardiovascular events.
• Bleeding risk should be carefully managed, and the use of a proton pump inhibitor is recommended to reduce the risk of further gastrointestinal bleeding.
• The FDA drug label for clopidogrel does not provide specific guidance on the management of antiplatelet therapy in patients with a duodenal ulcer and acute upper gastrointestinal bleeding.
• However, based on the available information, it is recommended to continue aspirin and clopidogrel as the benefits of antiplatelet therapy in preventing further cardiovascular events likely outweigh the risks of bleeding in this patient population 2, 2.
• Therefore, the recommended course of action is to continue aspirin and clopidogrel, while also managing the bleeding risk with a proton pump inhibitor and close monitoring.

From the Research

Antiplatelet Therapy Adjustments

The patient in question has a recent myocardial infarction (MI) and stent placement, and has developed a duodenal ulcer and acute upper gastrointestinal (GI) bleeding while on aspirin and clopidogrel. The following points should be considered:

• The patient is at high risk of GI bleeding due to the duodenal ulcer, and proton pump inhibitor (PPI) therapy is recommended to reduce this risk 3.
• Discontinuation of antiplatelet therapy, particularly clopidogrel, has been associated with a high risk of stent thrombosis and cardiac events 4, 5.
• The use of PPIs with clopidogrel may be associated with a reduced pharmacodynamic effect of clopidogrel, although the clinical significance of this interaction is debated 3, 6.

Recommended Course of Action

Based on the available evidence, the following recommendations can be made:

• Continuation of aspirin and clopidogrel is recommended, as discontinuation of these medications can increase the risk of stent thrombosis and cardiac events 4, 5.
• The addition of a PPI, such as pantoprazole, is recommended to reduce the risk of GI bleeding 3.
• The patient should be closely monitored for signs of GI bleeding and cardiac events, and the antiplatelet therapy regimen should be adjusted as needed.

Key Considerations

The following points should be considered when making decisions about antiplatelet therapy adjustments:

• The risk of stent thrombosis and cardiac events associated with discontinuation of antiplatelet therapy 4, 5.
• The risk of GI bleeding associated with continuation of antiplatelet therapy 3.
• The potential interaction between PPIs and clopidogrel, and the clinical significance of this interaction 3, 6.