What to do about dark stool after percutaneous coronary intervention (PCI) on Brilinta (ticagrelor), Aspirin (ASA), and Xarelto (rivaroxaban) for atrial fibrillation (AFib)?

Immediate Evaluation and Management of Dark Stool After PCI on Triple Antithrombotic Therapy

This patient requires urgent evaluation for gastrointestinal bleeding with immediate hemoglobin/hematocrit measurement, and you should strongly consider stopping aspirin while continuing rivaroxaban and ticagrelor (Brilinta) as a double therapy regimen. 1

Immediate Assessment

• Obtain complete blood count immediately to assess for anemia and quantify blood loss, as dark stool in a patient on triple therapy (aspirin, ticagrelor, and rivaroxaban) represents presumed GI bleeding until proven otherwise 1
• Check hemodynamic stability including blood pressure, heart rate, and signs of active bleeding 1
• Assess timing from PCI to determine whether you are still in the critical period requiring dual antiplatelet therapy or can safely de-escalate 1

Antithrombotic Medication Management

If Bleeding is Confirmed (Hemoglobin Drop or Active Bleeding):

Stop aspirin immediately while maintaining rivaroxaban and ticagrelor as double therapy, provided the patient is beyond the immediate peri-PCI period 1

The rationale for this approach:

• Triple therapy (OAC + aspirin + P2Y12 inhibitor) significantly increases bleeding risk without proportional ischemic benefit beyond the initial post-PCI period 1
• Current guidelines recommend double therapy (OAC + P2Y12 inhibitor) as the default strategy for most patients after PCI in atrial fibrillation, with aspirin discontinued at or shortly after hospital discharge 1
• For patients with high bleeding risk (which this patient now demonstrates), aspirin should be discontinued immediately or within 1 month maximum after PCI 1

Specific Timing Recommendations:

• If <1 month post-PCI and patient has high ischemic risk (left main stent, multivessel PCI, complex anatomy): Consider continuing triple therapy only if bleeding can be controlled and is minor 1
• If >1 month post-PCI: Definitively stop aspirin and continue double therapy with rivaroxaban plus ticagrelor 1
• If 6-12 months post-PCI: Consider stopping ticagrelor as well and continuing rivaroxaban monotherapy, especially given demonstrated high bleeding risk 1

Gastrointestinal Evaluation

Arrange urgent upper and lower endoscopy to identify the bleeding source, as this will guide further management and determine if antithrombotic therapy can be safely resumed 1

• Upper endoscopy should be performed first given that dark stool (melena) typically indicates upper GI source 1
• Colonoscopy may be needed if upper endoscopy is unremarkable, as diverticulosis and other lower GI sources are common in patients on antithrombotic therapy 1

Proton Pump Inhibitor Therapy

Initiate or optimize PPI therapy immediately with a non-CYP2C19-interfering agent 1

• Use pantoprazole or dexlansoprazole rather than omeprazole or esomeprazole to avoid drug-drug interactions with clopidogrel (though less relevant with ticagrelor) 1
• PPI should be considered mandatory in all patients on oral anticoagulation plus antiplatelet therapy to reduce GI bleeding risk 1

Critical Pitfall to Avoid

Do not discontinue rivaroxaban unless bleeding is life-threatening or uncontrollable, as this patient requires anticoagulation for atrial fibrillation stroke prevention 1

• The stroke risk from untreated atrial fibrillation typically outweighs bleeding risk once the acute bleeding is controlled 1
• If rivaroxaban must be held temporarily, resume within 24-48 hours once hemostasis is achieved and hemoglobin is stable 1

Consideration Regarding Ticagrelor vs. Clopidogrel

Consider switching from ticagrelor to clopidogrel if bleeding recurs or is difficult to control [1, @30@]

• Clopidogrel is the preferred P2Y12 inhibitor when combined with oral anticoagulation due to lower bleeding risk compared to ticagrelor or prasugrel 1
• Ticagrelor may be considered only in patients at high ischemic/thrombotic risk and low bleeding risk, which this patient clearly is not 1

Long-Term Strategy After Bleeding Resolution

Transition to double therapy (rivaroxaban + clopidogrel) without aspirin for up to 12 months post-PCI, then rivaroxaban monotherapy 1

• At 12 months post-PCI, discontinue all antiplatelet therapy and continue rivaroxaban alone at full stroke-prevention dose (20 mg daily, or 15 mg daily if creatinine clearance 30-49 mL/min) 1
• Ensure rivaroxaban dose is appropriate: If currently using reduced-dose rivaroxaban 15 mg daily as part of double therapy, increase to 20 mg daily once antiplatelet therapy is stopped 1

Monitoring Plan

• Recheck hemoglobin in 24-48 hours after stopping aspirin to ensure bleeding has stopped 1
• Monitor for signs of recurrent bleeding including continued dark stools, hemodynamic instability, or further hemoglobin drop 1
• Assess for thrombotic complications including stent thrombosis symptoms (chest pain, ST-elevation) given medication changes 1