When to restart Plavix (clopidogrel) or continue Aspirin (acetylsalicylic acid, ASA) in a patient with a history of CVA and recent MI due to GI bleed, with suspected hiatal hernia and recovered hemoglobin?

Management of Antiplatelet Therapy After GI Bleeding in a Patient with CVA and MI History

An EGD should be performed first to identify the source of bleeding before restarting Plavix (clopidogrel), and once hemostasis is confirmed, the patient should restart clopidogrel 75mg daily due to their high cardiovascular risk profile with both CVA and recent MI history. 1

Assessing the GI Bleed

This 78-year-old patient experienced a major GI bleed (evidenced by significant hemoglobin drop requiring transfusion) while on clopidogrel for secondary stroke prevention. The bleeding has now resolved with hemoglobin recovery to 13.5 g/dL.

Diagnostic Approach

• EGD is indicated first before attempting hiatal hernia correction
• The source of bleeding must be identified and treated before restarting antiplatelet therapy 1
• While hiatal hernia may be the suspected cause, it's essential to:
  • Confirm the exact bleeding site
  • Rule out other potential sources (e.g., ulcers, erosions, vascular malformations)
  • Assess for Cameron erosions which can occur in hiatal hernias 2

Antiplatelet Management Decision Algorithm

Step 1: Classify the Bleed

• This was a major bleed (hemodynamic instability with MI due to blood loss) 1
• Major bleeds require temporary discontinuation of antiplatelet therapy 1

Step 2: Assess Cardiovascular Risk

• High thrombotic risk patient with:
  • Prior CVA (within past year)
  • Recent MI (due to GI bleed)
  • This combination places patient at very high risk for recurrent cardiovascular events

Step 3: Determine Optimal Antiplatelet Strategy

When to Restart Antiplatelet Therapy:

• Restart clopidogrel once hemostasis is confirmed by EGD 1
• Timing considerations:
  • Ideally within 3-5 days after confirmed endoscopic hemostasis 1
  • Delaying beyond 7 days significantly increases cardiovascular risk 1

Which Antiplatelet Regimen:

• Single antiplatelet therapy with clopidogrel 75mg daily is the optimal choice 1, 3
• Rationale:
  1. Patient has history of both CVA and MI, requiring robust antiplatelet protection
  2. Clopidogrel is recommended as a safe and effective therapy for patients with prior MI 1
  3. Clopidogrel monotherapy is preferred over aspirin in patients with GI bleeding history 1, 4

Risk Reduction Strategies

Preventing Recurrent GI Bleeding:

1. Mandatory PPI therapy (e.g., pantoprazole 40mg daily) 1, 4

   • PPIs reduce GI bleeding risk in patients on antiplatelet therapy
   • Consider non-omeprazole/esomeprazole PPIs to avoid potential CYP2C19 interaction 3

2. Treat the underlying cause:

   • After EGD identifies the source, treat the specific lesion
   • If hiatal hernia with Cameron erosions is confirmed, PPI therapy alone may be sufficient without surgical repair 2

Monitoring:

• Close follow-up for signs of recurrent bleeding
• Monitor hemoglobin levels periodically
• Assess for symptoms of recurrent cardiovascular events

Common Pitfalls to Avoid

1. Do not restart dual antiplatelet therapy (aspirin + clopidogrel) as this significantly increases bleeding risk without proportional cardiovascular benefit in this setting 1

2. Do not delay EGD - identifying the bleeding source is critical before restarting antiplatelet therapy 1, 5

3. Do not permanently discontinue antiplatelet therapy - this patient's cardiovascular risk outweighs bleeding risk once the source is identified and treated 1

4. Do not proceed with hiatal hernia repair before EGD - the exact bleeding source must be confirmed first 2