How to manage a nose bleed in an elderly patient on Dual Antiplatelet Therapy (DAPT)?

Management of Nosebleed in an Elderly Patient on DAPT

In elderly patients on DAPT presenting with epistaxis, immediately control bleeding with local measures (firm nasal compression, topical vasoconstrictors, cautery, or packing) while continuing DAPT, and only discontinue one antiplatelet agent if bleeding persists despite aggressive local treatment or if there is no compelling indication for DAPT continuation. 1

Immediate Bleeding Control Strategy

Do not discontinue DAPT as your first intervention. The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends initiating first-line treatments prior to withdrawal of antiplatelet medications in the absence of life-threatening bleeding. 1

First-Line Local Control Measures (in order):

• Apply firm sustained compression to the lower third of the nose for 5-15 minutes with the patient seated, head tilted slightly forward, breathing through the mouth and spitting out blood rather than swallowing it. 1

• After compression, clean the nasal cavity of clots and apply topical vasoconstrictor (oxymetazoline or phenylephrine spray), which stops bleeding in 65-75% of cases. 1

• Perform anterior rhinoscopy after clot removal to identify the bleeding source. 1

• If a specific bleeding site is identified, anesthetize and perform nasal cautery using 75% silver nitrate, restricting cautery only to the active bleeding site (never bilateral cautery simultaneously due to septal perforation risk). 1

• Consider topical tranexamic acid as an alternative to phenylephrine-lidocaine packing, as it achieves faster bleeding control (mean 6.7 vs 11.5 minutes) and lower re-bleeding rates (6% vs 20%) in patients on antiplatelet therapy. 2

• If bleeding persists, proceed to nasal packing. Use resorbable packing specifically for patients on anticoagulant or antiplatelet medications to avoid complications from retained packing. 1

DAPT Modification Decision Algorithm

Critical distinction: Assess whether DAPT is actually indicated for this patient. 1

If Patient Has Stable CAD Without Recent PCI:

• Immediately discontinue one antiplatelet agent (typically the P2Y12 inhibitor like clopidogrel or ticagrelor), as there is no evidence supporting DAPT in conservatively managed stable CAD. 1

• Continue aspirin monotherapy after bleeding control is achieved. 1

• The European Heart Journal Task Force states that immediate discontinuation of one antiplatelet agent would have been indicated in stable CAD patients presenting with epistaxis, given the lack of evidence for DAPT in this indication. 1

If Patient Has Recent ACS or Recent PCI (<12 months):

• Continue DAPT and maximize local control measures first. 1

• Only consider discontinuing one agent if bleeding persists despite nasal tamponade and all local measures have been exhausted. 1

• Multidisciplinary consultation involving interventional cardiologists, cardiologists, and ENT specialists is required to balance stent thrombosis risk (particularly catastrophic if stent is in proximal LAD or if <2 weeks post-PCI) against bleeding severity. 1

• If ticagrelor must be discontinued, consider stopping at least 3 days before any required surgical intervention (though shorter duration may be acceptable). 1

• Do not use bridging therapy with enoxaparin as a substitute for DAPT, as low-molecular-weight heparins do not reduce stent thrombosis risk and may increase bleeding risk. 1

If Major Bleeding Requiring Intervention:

• Platelet transfusion may be considered for patients on aspirin or clopidogrel requiring emergency neurosurgery or with life-threatening bleeding, though evidence is limited and dose requirements are uncertain (clopidogrel may require higher platelet doses than aspirin). 1

• Platelet transfusion is ineffective for patients on ticagrelor due to its reversible binding mechanism. 1

Preventive Measures After Bleeding Control

Aggressive nasal mucosal moisturization is the cornerstone of preventing recurrence. 1

• Apply petroleum jelly to the anterior nasal septum 1-3 times daily, particularly before bedtime. 1

• Use regular saline nasal sprays throughout the day to maintain mucosal moisture. 1

• Consider bedside humidification during sleep, especially in dry climates or winter months. 1

• Optimize blood pressure control, though the causal relationship between hypertension and epistaxis remains controversial. 1

Patient Education and Follow-Up

• Document packing type placed (if applicable), timing and plan for removal if non-resorbable, post-procedure care, and warning signs requiring prompt reassessment. 1

• Educate patient about preventive measures, proper home treatment technique (compression method), and indications to seek emergency care (bleeding >30 minutes, hemodynamic instability, airway compromise). 1

• Document outcome within 30 days to assess treatment effectiveness. 1

• Assess for hereditary hemorrhagic telangiectasia if bilateral recurrent bleeding or visible nasal/oral telangiectasias are present, as this requires specialist referral. 1

Critical Pitfalls to Avoid

• Do not routinely discontinue DAPT without first attempting aggressive local control measures, as this increases thrombotic risk without proven benefit for non-life-threatening epistaxis. 1

• Do not continue DAPT long-term in stable CAD patients without specific indication (recent PCI), as this increases bleeding risk without reducing cardiovascular events. 1

• Do not use non-resorbable packing in antiplatelet patients without clear documentation and follow-up plan, as aspiration risk is increased in elderly patients, particularly those with cognitive impairment. 1, 3

• Do not perform bilateral cautery simultaneously due to septal perforation risk. 1