Should a patient with chronic ischemia, taking aspirin and clopidogrel, discontinue both medications before an endoscopy?

Management of Antiplatelet Therapy for Endoscopy in a Patient with Chronic Ischemia

For a patient with chronic ischemia and ECG signs of ischemia (T wave inversion) who is on dual antiplatelet therapy (aspirin and clopidogrel) and requires endoscopy, you should continue aspirin but discontinue clopidogrel 7 days before the procedure, consulting with an interventional cardiologist about the risk/benefit of this approach.

Assessment of Risk Factors

Thrombotic Risk Assessment

• Patient has chronic ischemia with ECG evidence (precordial T wave symmetric inversion)
• This places the patient in the high thrombotic risk category 1
• High-risk conditions include:
  • Ischemic heart disease
  • Cerebrovascular disease
  • Peripheral vascular disease

Endoscopic Procedure Risk

The management depends on whether the planned endoscopy is a high-risk or low-risk procedure:

Low-Risk Procedures:

• Diagnostic endoscopy with or without biopsy
• EUS without sampling
• Diagnostic enteroscopy without polypectomy

High-Risk Procedures:

• Polypectomy
• ERCP with sphincterotomy
• EMR/ESD
• Therapy of varices
• PEG placement
• EUS-guided sampling

Management Algorithm

For Dual Antiplatelet Therapy (DAPT):

1. For aspirin:

   • Continue aspirin regardless of procedure risk 1
   • Aspirin continuation is recommended even for high-risk endoscopic procedures

2. For clopidogrel (P2Y12 inhibitor):

   • For high-risk endoscopic procedures: Discontinue clopidogrel 7 days before the procedure 1
   • For low-risk endoscopic procedures: Can continue clopidogrel

3. Special considerations:

   • Consult with an interventional cardiologist about the risk/benefit of discontinuing clopidogrel 1
   • This is particularly important if the patient has:
     • Recent coronary stent placement (within 6-12 months for drug-eluting stent)
     • Recent acute coronary syndrome

4. Post-procedure management:

   • Resume clopidogrel 1-2 days after the procedure 1
   • Advise the patient about increased risk of post-procedure bleeding compared to patients not on antiplatelet therapy

Important Caveats and Considerations

• Bleeding risk: Clopidogrel increases the risk of bleeding during endoscopic procedures. If a patient is to undergo surgery and an antiplatelet effect is not desired, discontinue clopidogrel five days prior to surgery 2

• Thrombotic risk: Premature discontinuation of clopidogrel may increase the risk of cardiovascular events 2. This is why consultation with a cardiologist is essential.

• Duration of antiplatelet effect: Thienopyridines like clopidogrel inhibit platelet aggregation for the lifetime of the platelet (7-10 days), so withholding a dose will not be useful in managing an acute bleeding event 2

• Restart timing: If antiplatelet therapy is discontinued, it should be resumed up to 2-3 days after the procedure depending on the perceived hemorrhagic and thrombotic risks 1

• Melena management: If the patient is presenting with melena (GI bleeding) and is on dual antiplatelet therapy:

  • For patients with coronary stents, DAPT should be continued if possible 1
  • If interruption is necessary due to major hemorrhage, continue aspirin if the P2Y12 receptor antagonist (clopidogrel) is interrupted 1

Summary

The management strategy balances the risk of thrombotic events against the risk of procedural bleeding. For a patient with chronic ischemia on dual antiplatelet therapy:

1. Continue aspirin throughout the periendoscopic period
2. Discontinue clopidogrel 7 days before high-risk endoscopic procedures
3. Consult with an interventional cardiologist before making changes to antiplatelet therapy
4. Resume clopidogrel 1-2 days after the procedure
5. Monitor for signs of bleeding post-procedure

This approach is supported by the 2021 British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines 1, which provide strong recommendations based on moderate to high quality evidence.