Is a patient with CAD, HTN, HLD, PAF, and on Aspirin and Plavix (Clopidogrel) at low risk for an EGD?

Risk Assessment for EGD in a Patient on Dual Antiplatelet Therapy

This patient on aspirin and clopidogrel with CAD, HTN, HLD, PAF, and a history of LAD stenting is at moderate risk for EGD, not low risk, due to the increased bleeding risk from dual antiplatelet therapy.

Patient Risk Assessment

• The patient has multiple cardiovascular risk factors including coronary artery disease (CAD), hypertension (HTN), hyperlipidemia (HLD), and paroxysmal atrial fibrillation (PAF) 1
• The patient has had a prior LAD stent placement and is currently on dual antiplatelet therapy (DAPT) with aspirin and clopidogrel 1
• Normal left ventricular function with EF 55-60% and only mild valvular abnormalities indicate good cardiac function 1

Bleeding Risk with Dual Antiplatelet Therapy

• Patients on DAPT have an increased risk of bleeding during endoscopic procedures compared to those on single antiplatelet therapy 1
• The 2018 Asian Pacific Association of Gastroenterology guidelines specifically note that patients on DAPT have higher bleeding risk during endoscopic procedures 1
• For patients with coronary stents on DAPT, guidelines recommend against withholding both antiplatelet agents due to high risk of stent thrombosis 1

Management Recommendations for EGD

• For patients on DAPT undergoing endoscopic procedures, consultation with a cardiologist is recommended before any modification of antiplatelet therapy 1
• If temporary discontinuation is considered necessary, guidelines recommend continuing aspirin and withholding clopidogrel temporarily for high-risk endoscopic procedures 1
• The timing of stent placement is critical - if the coronary stent was placed within the past 6-12 months, the risk of stent thrombosis with antiplatelet discontinuation is significantly higher 1

Specific Recommendations Based on Stent Timing

• If the LAD stent was placed within the last 12 months (stent placed in 06/2025 as per history), the patient is at high risk for stent thrombosis if antiplatelet therapy is interrupted 1
• For patients within 12 months of drug-eluting stent placement, guidelines recommend maintaining at least aspirin therapy during the periendoscopic period 1
• Early resumption of P2Y12 receptor inhibitor (clopidogrel) is recommended, preferably within 5 days after endoscopic procedure if temporarily discontinued 1

Risk Mitigation Strategies

• Consider performing EGD without interruption of aspirin therapy, as this approach has been shown to be relatively safe 1
• If clopidogrel must be temporarily discontinued, it should be stopped 5-7 days before the procedure and resumed as soon as hemostatic risk allows 1
• Proton pump inhibitors should be used perioperatively to reduce GI bleeding risk in patients who must remain on antiplatelet therapy 1
• The endoscopist should be prepared for potential bleeding complications with appropriate hemostatic tools available 1

Conclusion

The patient should be considered at moderate risk for EGD, not low risk, due to the dual antiplatelet therapy. The procedure can still be performed with appropriate precautions and risk mitigation strategies in place, but the bleeding risk should be acknowledged and prepared for accordingly 1.