What is the management of antiplatelet therapy, including aspirin and P2Y12 inhibitors (e.g. clopidogrel), in patients with a history of cardiovascular disease undergoing Endoscopic Ultrasonography Fine Needle Aspiration (EUS FNA) or Fine Needle Biopsy (FNB)?

Management of Antiplatelet Therapy for EUS FNA/FNB

For patients undergoing EUS-FNA or EUS-FNB, discontinue P2Y12 inhibitors (clopidogrel, prasugrel, ticagrelor) 7 days before the procedure in patients at low thrombotic risk, while continuing aspirin if the patient is on dual antiplatelet therapy. 1

Risk Stratification of the Procedure

EUS with fine needle aspiration or biopsy is classified as a high-risk endoscopic procedure for bleeding complications. 1 This classification drives the management strategy for antithrombotic medications.

Management Based on Thrombotic Risk

Low Thrombotic Risk Patients

Low thrombotic risk includes:

• Ischemic heart disease without coronary stent 1
• Cerebrovascular disease 1
• Peripheral vascular disease 1

For these patients:

• Stop clopidogrel, prasugrel, or ticagrelor 7 days before the procedure 1
• Continue aspirin if already prescribed (if on dual antiplatelet therapy) 1
• Restart the P2Y12 inhibitor 1-2 days after the procedure if no bleeding complications 1

High Thrombotic Risk Patients

High thrombotic risk includes:

• Drug-eluting coronary stent placed within 6-12 months 1
• Bare metal coronary stent placed within 1 month 1
• Recent acute coronary syndrome 1

For these patients:

• Continue aspirin 1
• Liaise with a consultant interventional cardiologist about the risk/benefit of discontinuing the P2Y12 receptor antagonist 1
• Consider temporary cessation only after cardiology consultation 1
• If the P2Y12 inhibitor must be stopped, restart preferably within 5 days after endoscopic hemostasis 1

Aspirin Monotherapy

For patients on aspirin alone:

• Continue aspirin for secondary prevention (history of MI, stroke, or peripheral arterial disease) 1
• Discontinue aspirin if prescribed for primary prevention only 1

The evidence shows aspirin continuation does not significantly increase bleeding risk during EUS-FNA. 1, 2 A prospective study found 0% bleeding events (0/26) in patients continuing aspirin/NSAIDs during EUS-FNA. 2

Evidence Quality and Nuances

The 2021 BSG/ESGE guidelines 1 represent the most recent and authoritative recommendations, updating the 2016 version 1 with stronger evidence (moderate quality) for the 7-day discontinuation period for P2Y12 inhibitors. The Asian guidelines 1 note that bleeding risk from EUS-FNA is approximately 1%, rising to 6% for pancreatic cystic lesions. 1

Important caveat: There is limited direct evidence on continuation of non-aspirin antiplatelet drugs during EUS-FNA. 1 However, retrospective studies show that even when clopidogrel is continued, bleeding events remain rare (0-1.6%). 3, 4, 5 One study found no severe bleeding events in patients continuing aspirin or cilostazol during EUS-FNA. 4

Post-Procedure Management

• Resume discontinued antiplatelet therapy 1-3 days after the procedure depending on perceived hemorrhagic and thrombotic risks 1
• For high-risk patients with coronary stents, prioritize earlier resumption (within 5 days maximum) 1
• Advise patients of increased post-procedure hemorrhage risk compared to those not on antiplatelet agents 1

Common Pitfalls to Avoid

• Never stop both antiplatelet agents in patients with recent coronary stents without cardiology consultation 1
• Do not routinely stop aspirin in patients on secondary prevention unless the bleeding risk is prohibitive 1
• Avoid delaying resumption of P2Y12 inhibitors beyond 5 days in high-risk patients, as this increases stent thrombosis risk 1
• Do not assume all cardiovascular disease patients have the same thrombotic risk—timing of stent placement is critical 1