Which antiplatelet medications, such as P2Y12 inhibitors (e.g. clopidogrel, prasugrel, ticagrelor), should be stopped after percutaneous transluminal coronary angioplasty (PTCA) in the event of epistaxis?

Management of Antiplatelet Therapy Post-PTCA When Epistaxis Occurs

When epistaxis occurs after PTCA, discontinue the P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor) while continuing aspirin, as demonstrated in a real-world case where epistaxis persisted despite clopidogrel discontinuation, ultimately requiring aspirin cessation as well. 1

Initial Management Strategy

Stop the P2Y12 inhibitor first, maintain aspirin:

• The P2Y12 inhibitor should be discontinued as the initial step when epistaxis occurs, as this addresses the more potent component of dual antiplatelet therapy (DAPT) while preserving some antiplatelet protection 1
• Aspirin should be continued initially at the maintenance dose of 75-100 mg daily, as it provides essential cardiovascular protection with lower bleeding risk than P2Y12 inhibitors 1
• Local hemostatic measures (anterior nasal tamponade) should be implemented concurrently to control the bleeding 1

If Epistaxis Persists Despite P2Y12 Inhibitor Discontinuation

Discontinue aspirin as well:

• If epistaxis continues despite stopping the P2Y12 inhibitor, aspirin must also be discontinued, as evidenced by the case where bleeding persisted for 2-3 weeks until both agents were stopped 1
• This decision requires careful risk-benefit assessment, particularly in patients with recent stent placement who are at high thrombotic risk 1

Timing Considerations Based on Stent Type and Clinical Context

The decision to stop antiplatelet therapy depends on when the stent was placed:

For patients >12 months post-PCI:

• Both P2Y12 inhibitor and aspirin can be safely discontinued if necessary, as the mandatory DAPT period has been completed 1
• Aspirin monotherapy is typically continued indefinitely, but can be interrupted for significant bleeding 1

For patients 6-12 months post-DES:

• Discontinue the P2Y12 inhibitor first, as the critical re-endothelialization period has largely passed 1
• Continue aspirin if hemostasis can be achieved with P2Y12 inhibitor cessation alone 1
• If both agents must be stopped, resume therapy as soon as bleeding is controlled 1

For patients <6 months post-DES or <1 month post-BMS:

• This represents a high-risk scenario where stent thrombosis risk is substantial 1
• Consultation with the interventional cardiologist is mandatory before discontinuing any antiplatelet agent 1, 2
• Consider otorhinolaryngology consultation for aggressive local hemostatic measures to avoid stopping DAPT 1
• If DAPT must be stopped, the duration should be minimized and therapy resumed urgently once hemostasis is achieved 1

Specific P2Y12 Inhibitor Considerations

The choice of which P2Y12 inhibitor to stop matters:

• Clopidogrel: Platelet function returns to normal 5-7 days after discontinuation due to irreversible platelet inhibition 1
• Prasugrel: More potent than clopidogrel; requires 7-10 days for platelet function recovery 1
• Ticagrelor: Reversible inhibitor; platelet function recovers within 3-5 days after discontinuation 1, 3

Resumption of Antiplatelet Therapy

Restart antiplatelet therapy as soon as hemostasis is achieved:

• P2Y12 inhibitor should be restarted first, as it provides the most critical protection against stent thrombosis in the early post-PCI period 1
• Aspirin can be added back once bleeding risk is deemed acceptable 1
• The total duration of DAPT should still reach the recommended 12 months for ACS or DES patients 1

Additional Management Considerations

Address contributing factors:

• Optimize blood pressure control, as uncontrolled hypertension was a contributing factor in the guideline case example 1
• Consider proton pump inhibitor therapy if there are concurrent gastrointestinal bleeding risk factors, though this is less relevant for epistaxis 1
• Evaluate for other bleeding risk factors including thrombocytopenia, coagulopathy, or anatomic nasal abnormalities 1

Critical Pitfalls to Avoid

• Never discontinue both antiplatelet agents simultaneously in patients <6 months post-stent without cardiology consultation, as this dramatically increases stent thrombosis risk with potential for myocardial infarction or death 1, 2
• Do not assume epistaxis will resolve with continued DAPT, as the case example demonstrates that persistent bleeding may require escalating antiplatelet discontinuation 1
• Avoid restarting DAPT before adequate hemostasis is achieved, as this will perpetuate the bleeding 1