How is bleeding managed in patients on antiplatelet therapy?

Management of Bleeding in Patients on Antiplatelet Therapy

For patients experiencing bleeding while on antiplatelet therapy, immediately assess bleed severity and stop antiplatelet agents for major bleeding, while providing local therapy, supportive care, and addressing the bleeding source. 1, 2

Assessment of Bleeding Severity

Determine if bleeding meets criteria for major bleeding:

• Bleeding at a critical site (e.g., intracranial, spinal, intraocular)
• Hemodynamic instability
• Clinically overt bleeding with hemoglobin decrease ≥2 g/dL or requiring ≥2 units of blood transfusion 1

Management Algorithm Based on Bleeding Severity

For Major Bleeding:

1. Stop antiplatelet agent(s) immediately
2. Provide local therapy/manual compression
3. Administer supportive care and volume resuscitation
4. Assess and manage comorbidities that contribute to bleeding (e.g., thrombocytopenia, uremia, liver disease)
5. Consider surgical/procedural management of bleeding site 1, 2

For Non-Major Bleeding:

1. Consider temporarily stopping antiplatelet agent(s)
2. Provide local therapy/manual compression
3. Assess for comorbidities contributing to bleeding
4. For minor, non-critical bleeding, consider continuing antiplatelet therapy if the clinical indication is strong 1, 2

Special Considerations

Risk Factors for Increased Bleeding:

• Body weight <60 kg
• Age ≥75 years (particularly with prasugrel)
• Concomitant use of medications that increase bleeding risk (e.g., warfarin, heparin, NSAIDs)
• History of prior stroke or TIA (contraindication for prasugrel) 3

Platelet Transfusion:

• Consider platelet transfusion for severe or life-threatening bleeding in patients on antiplatelet therapy
• Efficacy depends on:
  • Type of antiplatelet agent (less effective for ticagrelor)
  • Time since last dose
  • Bleeding mechanism and site 4

Decision to Restart Antiplatelet Therapy

After bleeding control, assess:

1. Is there a clinical indication for continued antiplatelet therapy?
2. Does the patient have factors that contraindicate restarting?
   • Bleeding at a critical site
   • High risk of rebleeding
   • Unidentified source of bleeding
   • Planned surgical procedures 1, 2

Timing of Restart:

• For patients with recent coronary stents or high cardiovascular risk, coordinate with cardiology
• Discontinuing antiplatelet therapy, particularly in the first few weeks after acute coronary syndrome, increases the risk of subsequent cardiovascular events 3
• When possible, discontinue prasugrel at least 7 days prior to any surgery 3

Pitfalls to Avoid

1. Premature discontinuation of antiplatelet therapy in patients with recent stent placement - increases risk of stent thrombosis
2. Failure to recognize major bleeding - delayed intervention can lead to poor outcomes
3. Inappropriate platelet transfusion - may not be effective for all antiplatelet agents and carries its own risks
4. Neglecting to adjust dosing based on patient factors - consider lower maintenance doses (e.g., 5 mg prasugrel) in patients <60 kg 3
5. Overlooking drug interactions - concomitant medications may increase bleeding risk

Monitoring After Bleeding Event

• Assess hemodynamic stability and hemoglobin levels
• Monitor for recurrent bleeding
• If antiplatelet therapy is restarted, consider lower doses or alternative agents with lower bleeding risk
• Regular follow-up to reassess the balance between thrombotic and bleeding risks 5, 6