Management of a Patient with Recent TAVR on ASA and Plavix Who Has Fallen
After a fall in a patient with recent TAVR on dual antiplatelet therapy (ASA and clopidogrel), the patient should continue both medications unless there is evidence of active bleeding or high bleeding risk, as the thrombotic risk of discontinuation typically outweighs bleeding concerns. 1
Initial Assessment After Fall
Immediate evaluation:
- Assess for signs of external bleeding, particularly at access sites
- Check for neurological deficits suggesting intracranial hemorrhage
- Evaluate vital signs for hemodynamic instability
- Obtain complete blood count to establish baseline hemoglobin
Imaging considerations:
- Head CT if any neurological symptoms or loss of consciousness occurred
- Imaging of injured areas to rule out fractures or internal bleeding
- Consider echocardiography if concern for valve dysfunction or pericardial effusion
Management Algorithm Based on Bleeding Risk
Scenario 1: No Evidence of Bleeding
- Continue dual antiplatelet therapy (ASA 75-100mg daily and clopidogrel 75mg daily)
- Monitor for delayed bleeding complications
- Ensure adequate hydration and mobility
Scenario 2: Minor Bleeding
- Continue ASA but temporarily hold clopidogrel for 1-3 days if minor bleeding occurs
- Resume clopidogrel once bleeding is controlled
- More frequent monitoring of hemoglobin
Scenario 3: Major Bleeding
- Temporarily discontinue both antiplatelet agents
- Provide appropriate hemostatic measures and blood products as needed
- Consult with TAVR team regarding resumption strategy
- Resume ASA first when safe, followed by clopidogrel if possible
Rationale for Continuing Antiplatelet Therapy
The American College of Cardiology guidelines recommend dual antiplatelet therapy with ASA (75-100mg daily lifelong) and clopidogrel (75mg daily for 3-6 months) after TAVR to prevent valve thrombosis and thromboembolic events 1. Premature discontinuation increases the risk of valve thrombosis, which can lead to significant morbidity and mortality.
The risk of thrombotic complications is highest in the first 3 months after TAVR, with the ACC noting that antiplatelet therapy is crucial during this period 1. This thrombotic risk typically outweighs bleeding concerns unless major active bleeding is present.
Fall Risk Mitigation
- Assess for orthostatic hypotension, which can be exacerbated by antihypertensive medications
- Consider physical therapy evaluation for gait training and assistive devices
- Implement home safety modifications
- Early mobilization and rehabilitation as recommended by the American College of Cardiology 2
Special Considerations
- Timing after TAVR: The risk of discontinuing antiplatelet therapy is highest within the first 3 months after TAVR
- Patients with concurrent anticoagulation: If the patient is also on anticoagulation for atrial fibrillation or other indications, consider maintaining only ASA and anticoagulation while discontinuing clopidogrel, as triple therapy significantly increases bleeding risk 1
- Elderly patients: These patients are at higher risk for both falls and bleeding complications, requiring more careful monitoring
Follow-up Recommendations
- Early follow-up with TAVR team (within 1-2 weeks if fall occurred within 30 days of TAVR)
- Regular monitoring of hemoglobin levels
- Reassess fall risk and implement preventive strategies
- Consider cardiac rehabilitation to improve functional capacity and reduce fall risk 2
The balance between thrombotic and bleeding risks must be carefully weighed, but in most cases, the benefit of maintaining dual antiplatelet therapy after TAVR outweighs the risk of bleeding unless active major hemorrhage is present.