Should aspirin (acetylsalicylic acid) and Brilinta (ticagrelor) be discontinued in a patient who had a ST-elevation myocardial infarction (STEMI) 2 months ago and now presents with hematuria with clots?

From the Guidelines

I strongly recommend temporarily stopping both aspirin and ticagrelor (Brilinta) in this patient with hematuria with clots who had a STEMI 2 months ago, but this decision requires urgent urological evaluation and cardiology consultation. The presence of blood clots in urine suggests significant bleeding that warrants investigation and may be exacerbated by dual antiplatelet therapy 1. After stopping these medications, the patient should undergo immediate urological assessment to determine the cause of bleeding (possibilities include urinary tract infection, kidney stones, or malignancy).

Key Considerations

• Since the patient is only 2 months post-STEMI, they remain at elevated risk for stent thrombosis or recurrent cardiac events if antiplatelet therapy is discontinued for too long 1.
• A cardiologist should be consulted to determine the safest approach, which may include temporarily switching to a single antiplatelet agent or restarting dual therapy as soon as the bleeding is controlled.
• The timing of restarting therapy depends on the severity and cause of bleeding, but generally should occur as soon as safely possible.
• The risk-benefit assessment is crucial here, balancing the risk of recurrent cardiac events against ongoing bleeding complications 1.

Management Approach

• Urgent urological evaluation to determine the cause of bleeding.
• Cardiology consultation to assess the risk of recurrent cardiac events and to determine the safest approach for antiplatelet therapy.
• Consideration of temporarily switching to a single antiplatelet agent or restarting dual therapy as soon as the bleeding is controlled.
• Close monitoring of the patient's condition and adjustment of the management plan as needed.

From the Research

Discontinuation of Aspirin and Brilinta in STEMI Patients with Hematuria

• The decision to discontinue aspirin and Brilinta (ticagrelor) in a patient who had a ST-elevation myocardial infarction (STEMI) 2 months ago and now presents with hematuria with clots should be based on the patient's individual risk factors and medical history 2, 3, 4, 5, 6.
• Studies have shown that dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor such as ticagrelor is recommended for patients with STEMI, but the risk of bleeding complications should also be considered 2, 4, 5.
• The PRECISE-DAPT score can be used to assess the patient's bleeding risk, and a score ≥25 indicates a high bleeding risk 5.
• In patients with high bleeding risk, the benefits of more intensive anti-ischemic therapy with ticagrelor may not outweigh the risks of major bleeding, and clopidogrel may be a safer alternative 5, 6.
• However, the choice of antiplatelet therapy should be individualized based on the patient's specific characteristics, medical history, and risk factors 5, 6.

Bleeding Risk and Antiplatelet Therapy

• The risk of bleeding complications is higher with ticagrelor compared to clopidogrel, especially in patients with high bleeding risk 2, 5, 6.
• The incidence of major bleeding events was higher with ticagrelor compared to clopidogrel in some studies, but the difference was not statistically significant in others 5, 6.
• The decision to discontinue aspirin and Brilinta should be based on a careful assessment of the patient's bleeding risk and the potential benefits of continuing antiplatelet therapy 2, 3, 4, 5, 6.

Management of STEMI Patients with Hematuria

• Patients with STEMI who present with hematuria with clots should be evaluated for underlying causes of bleeding, such as urinary tract infection or kidney stones 2, 3, 4.
• The management of STEMI patients with hematuria should be individualized based on the patient's specific characteristics, medical history, and risk factors 2, 3, 4, 5, 6.
• The decision to discontinue aspirin and Brilinta should be made in consultation with a cardiologist and a urologist, and should be based on a careful assessment of the patient's bleeding risk and the potential benefits of continuing antiplatelet therapy 2, 3, 4, 5, 6.