How is bleeding managed in patients on dual antiplatelet (DAPT) therapy?

Management of Bleeding in Patients on Dual Antiplatelet Therapy

For patients experiencing bleeding while on dual antiplatelet therapy (DAPT), do not stop both antiplatelet agents simultaneously due to high risk of stent thrombosis; instead, continue aspirin while temporarily withholding the P2Y12 inhibitor, and resume the P2Y12 inhibitor as soon as adequate hemostasis is achieved. 1

Initial Assessment and Stratification

When managing bleeding in patients on DAPT, the approach depends on bleeding severity:

For Major/Life-Threatening Bleeding:

1. Resuscitation measures:

   • Restore hemodynamic stability with crystalloid fluids
   • Maintain hemoglobin ≥7 g/dL (≥8 g/dL in patients with coronary artery disease) 1
   • Correct hypothermia and acidosis which can worsen coagulopathy

2. Immediate interventions:

   • Early involvement of appropriate specialists (gastroenterology, surgery, interventional radiology) for definitive management 1
   • Apply local hemostatic measures where possible
   • For GI bleeding, administer IV proton pump inhibitors 1

3. Antiplatelet management:

   • Continue aspirin if possible
   • Temporarily withhold P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) 1
   • Do not discontinue both agents simultaneously due to high risk of stent thrombosis 1

For Minor/Non-Major Bleeding:

1. Local measures to control bleeding
2. Temporary interruption of P2Y12 inhibitor may be considered while continuing aspirin
3. Do not routinely reverse anticoagulation for non-major bleeds 1

Site-Specific Management

Gastrointestinal Bleeding:

• Immediate IV PPI administration
• Urgent endoscopy for diagnosis and treatment
• For patients with drug-eluting coronary stents, resume P2Y12 inhibitor preferably within 5 days after endoscopic hemostasis 1

Intracranial Hemorrhage:

• Neurosurgical consultation
• More aggressive approach to antiplatelet discontinuation may be needed
• The European Society of Cardiology does not recommend routine platelet transfusion for patients on antiplatelet therapy with ICH, as this may worsen outcomes 1

Resumption of Therapy After Bleeding

1. Timing:

   • Resume P2Y12 inhibitor once adequate hemostasis is achieved 1
   • For patients with drug-eluting coronary stents, aim to resume P2Y12 inhibitor within 5 days 1

2. Medication selection:

   • Consider switching to a less potent P2Y12 inhibitor (e.g., from ticagrelor/prasugrel to clopidogrel) to reduce bleeding risk
   • Maintain low-dose aspirin (75-100 mg daily) 2

3. Duration adjustment:

   • Consider shortened DAPT duration based on individual bleeding risk assessment 2
   • For high bleeding risk patients, consider DAPT duration of 1-6 months for stable CAD patients after PCI and 6 months for ACS patients 2

Special Considerations for Patients on Triple Therapy

For patients on DAPT plus oral anticoagulation (triple therapy):

1. If bleeding occurs:

   • For minor bleeding, consider reducing triple therapy to dual therapy (OAC + clopidogrel) 2
   • For major bleeding, temporarily withhold antiplatelet agents if necessary 2

2. Duration of triple therapy:

   • Limit triple therapy to a maximum of 6 months or consider omitting after hospital discharge 2
   • For high bleeding risk patients, consider triple therapy for only 1 month, then dual therapy (OAC + clopidogrel) for up to 12 months 2

Common Pitfalls to Avoid

1. Never discontinue both antiplatelet agents simultaneously in patients with coronary stents due to high risk of stent thrombosis 1, 2

2. Avoid routine platelet transfusion for patients on antiplatelet therapy with bleeding, as evidence suggests this may not reduce rebleeding and could be associated with higher mortality 1

3. Do not delay endoscopy for life-threatening bleeding until normalization of coagulation parameters 1

4. Avoid prolonging triple therapy unnecessarily as it significantly increases bleeding risk 2

5. Do not use prasugrel or ticagrelor with anticoagulation due to excessive bleeding risk 2

By following these evidence-based recommendations, clinicians can effectively manage bleeding complications in patients on DAPT while minimizing both thrombotic and hemorrhagic risks.