How to manage a patient with recent TAVR on Aspirin (acetylsalicylic acid) and Plavix (clopidogrel) who fell, has a closed pelvic fracture, and shows signs of mild anemia and thrombocytopenia?

Management of Antiplatelet Therapy in a Post-TAVR Patient with Pelvic Fracture

In a patient with recent TAVR on dual antiplatelet therapy (ASA and clopidogrel) who has sustained a closed pelvic fracture with mild anemia and thrombocytopenia, temporarily discontinuing clopidogrel while maintaining aspirin therapy is recommended.

Assessment of Current Situation

The patient presents with:

• Recent TAVR (transcatheter aortic valve replacement)
• Currently on dual antiplatelet therapy (DAPT) with ASA and clopidogrel
• Closed pelvic fracture following a fall
• Negative CT scan (no active bleeding)
• Mild anemia (Hgb drop from 11.3 to 10.8)
• Mild thrombocytopenia (platelet drop from 224 to 190)

Management Algorithm

Step 1: Assess Bleeding Risk vs. Thrombotic Risk

• Bleeding risk: High due to pelvic fracture, mild anemia, and thrombocytopenia
• Thrombotic risk: Moderate due to recent TAVR

Step 2: Antiplatelet Management

1. Temporarily discontinue clopidogrel

   • Clopidogrel significantly increases bleeding risk 1
   • Effect will persist for 5-7 days after discontinuation due to irreversible platelet inhibition

2. Continue low-dose aspirin (75-100 mg daily)

   • Provides baseline protection against valve thrombosis 2
   • Lower bleeding risk than dual antiplatelet therapy

3. Monitor hemoglobin and platelet counts daily

   • Watch for further decreases that might indicate ongoing bleeding
   • Consider transfusion if hemoglobin drops below 8 g/dL or if patient becomes symptomatic

Step 3: Fracture Management

• Orthopedic consultation for management of closed pelvic fracture
• Consider non-surgical management if fracture is stable
• Avoid NSAIDs for pain management due to antiplatelet effects

Step 4: Resumption of Dual Antiplatelet Therapy

• Resume clopidogrel after 5-7 days if:
  • No evidence of ongoing bleeding
  • Hemoglobin stabilizes
  • Platelet count normalizes

Evidence-Based Rationale

The 2017 ACC Expert Consensus recommends ASA 75-100 mg daily lifelong after TAVR, with clopidogrel 75 mg daily for 3-6 months 2. However, in the setting of significant bleeding risk, temporary modification of this regimen is appropriate.

The FDA label for clopidogrel notes that it significantly increases bleeding risk, especially when combined with other antithrombotic agents 1. The drug label specifically states: "If clopidogrel must be temporarily discontinued (e.g., to treat bleeding), restart it as soon as possible" 1.

Recent evidence suggests that single antiplatelet therapy may be sufficient in many TAVR patients, with some studies showing that clopidogrel monotherapy was associated with lower cardiovascular mortality compared to aspirin monotherapy 3. This supports the safety of temporarily discontinuing one agent in the setting of bleeding risk.

Important Considerations and Pitfalls

• Avoid complete discontinuation of all antiplatelet therapy unless life-threatening bleeding occurs, as this significantly increases valve thrombosis risk
• Do not substitute with NSAIDs for pain management, as they can increase bleeding risk
• Monitor for signs of valve thrombosis (new heart failure symptoms, dyspnea, or systemic embolism)
• Consider echocardiography before hospital discharge to assess valve function
• Beware of drug interactions that might affect platelet function or clopidogrel metabolism

Follow-up Plan

• Daily CBC to monitor hemoglobin and platelet counts
• Reassess bleeding risk in 48-72 hours
• Consider resuming clopidogrel after 5-7 days if bleeding risk has resolved
• Schedule follow-up echocardiography within 30 days to assess valve function

This approach balances the need to minimize bleeding risk while maintaining sufficient protection against valve thrombosis in a patient with recent TAVR.