Is initiation of dual anti-platelet therapy (DAPT) contraindicated in patients with acute conjunctival hemorrhage?

Dual Antiplatelet Therapy in Patients with Acute Conjunctival Hemorrhage

Acute conjunctival hemorrhage is not a contraindication for initiating dual antiplatelet therapy (DAPT), as the risk of thrombotic events from withholding or discontinuing DAPT generally outweighs the risk of this minor bleeding event. 1

Risk Assessment and Clinical Decision-Making

• Conjunctival hemorrhage is not classified as a high-risk bleeding condition in major antiplatelet therapy guidelines 1
• The thrombotic risk of discontinuing antiplatelet therapy significantly outweighs the risk of progression or complications from conjunctival hemorrhage 1
• Interrupting antiplatelet therapy is associated with a three-fold increased risk of cardiovascular or cerebrovascular events 1
• 70% of thrombotic events occur within 7-10 days after antiplatelet interruption, making even brief discontinuation potentially dangerous 1

Management Recommendations

• For patients with acute coronary syndrome (ACS), DAPT with a P2Y12 inhibitor plus aspirin is strongly recommended for 12 months, regardless of the presence of conjunctival hemorrhage 2, 3
• In patients with very high-risk TIA or minor ischemic stroke, DAPT with clopidogrel and aspirin should be given for 21-30 days as recommended, despite conjunctival hemorrhage 2, 4
• For patients with conjunctival hemorrhage who are initiating DAPT:
  • Use local measures to manage the conjunctival hemorrhage rather than modifying the antiplatelet regimen 1
  • Consider ophthalmology consultation for management of the hemorrhage while maintaining DAPT 1

Special Considerations

• If the patient has recurrent or severe conjunctival hemorrhages plus other bleeding risk factors:
  • Maintain aspirin therapy (at least 81 mg daily) 1, 3
  • Consider cardiology consultation regarding the risk/benefit of P2Y12 inhibitor selection 1
  • Consider prescribing a proton pump inhibitor to reduce overall bleeding risk 3

Evidence on Bleeding Risk with DAPT

• The estimated rate of emergency department visits for acute hemorrhages with DAPT is 1.2 per 1000 outpatient prescription visits, compared to 2.5 per 1000 for warfarin 5
• Approximately 60% of emergency department visits for bleeding events with DAPT consist of epistaxis or other minor hemorrhages 5
• A meta-analysis of intraocular bleeding with potent P2Y12 inhibitors found no statistically significant increase in risk compared to clopidogrel (risk ratio 0.89,95% CI 0.58 to 1.36) 6

Common Pitfalls to Avoid

• Prematurely discontinuing DAPT based solely on the presence of conjunctival hemorrhage 1
• Failing to distinguish between minor bleeding events (like conjunctival hemorrhage) and major bleeding events that might warrant therapy modification 1
• Not considering the high thrombotic risk associated with discontinuing antiplatelet therapy, especially in patients with recent coronary stents or cerebrovascular events 1, 3
• Discontinuing DAPT within the first month after stent placement, which carries particularly high risk 3

Measures to Minimize Bleeding Risk While Maintaining DAPT

• Use radial over femoral access for coronary procedures when applicable 3
• Maintain a daily aspirin dose of 75-100 mg when used with DAPT 3
• Consider prescribing a proton pump inhibitor in combination with DAPT to reduce gastrointestinal bleeding risk 3