What is the best approach for managing a patient with CAD, currently on DAPT with Brilinta (ticagrelor) and aspirin, who also has bleeding hemorrhoids and a pacemaker, considering discontinuation of Brilinta and continuation of aspirin alone for CAD secondary prevention?

Managing DAPT Discontinuation in a CAD Patient with Bleeding Hemorrhoids

Discontinue Brilinta (ticagrelor) and continue aspirin 75-100 mg daily for long-term secondary prevention in this patient who has completed an appropriate duration of DAPT and now has active bleeding hemorrhoids. 1

Rationale for DAPT Discontinuation

Your clinical decision is strongly supported by current guidelines:

• The 2024 ESC Guidelines recommend aspirin 75-100 mg daily lifelong after an initial period of DAPT in CCS patients with prior MI or remote PCI 1. This represents the standard of care for long-term secondary prevention.

• Clopidogrel 75 mg daily is recommended as a safe and effective alternative to aspirin monotherapy 1, and recent 2025 evidence demonstrates clopidogrel may actually be superior to aspirin for preventing major adverse cardiovascular events (MACCE) with no increase in bleeding risk 2. However, given your patient's active bleeding, aspirin alone is the most appropriate initial step.

• The duration of DAPT matters critically: The default duration is 12 months for ACS patients 1, 3, and 6 months for stable CAD patients undergoing PCI 1. Your patient has completed this period, making discontinuation of the P2Y12 inhibitor appropriate.

Managing the Bleeding Risk

A proton pump inhibitor is mandatory for this patient 1:

• The 2024 ESC Guidelines provide a Class I recommendation for PPI use in patients at increased risk of gastrointestinal bleeding for the duration of antithrombotic therapy 1
• This applies to both DAPT and single antiplatelet therapy when bleeding risk is elevated 1
• Prescribe a PPI (such as pantoprazole or rabeprazole, which have lower drug interactions than omeprazole) immediately 1

Timing Considerations for Hemorrhoid Banding

Continue aspirin through the hemorrhoid banding procedure 1:

• The 2016 BSG/ESGE Guidelines recommend continuing aspirin for all endoscopic procedures except high-risk interventions like endoscopic submucosal dissection 1
• Hemorrhoid banding is considered a low-to-moderate risk procedure where aspirin continuation is generally safe 1
• The thrombotic risk from aspirin discontinuation (3-fold increased risk of cardiovascular events) far outweighs the bleeding risk from continuing aspirin during hemorrhoid banding 1

However, coordinate with gastroenterology:

• If they prefer aspirin discontinuation for the procedure, stop it only 5-7 days before and resume immediately after hemostasis is achieved 1
• Never discontinue aspirin for more than 7-10 days, as 70% of thrombotic events occur within this window 1

Critical Safety Considerations

The risk of premature DAPT discontinuation is highest in the first month after stenting 1, 3:

• Your patient is well beyond this critical window, making ticagrelor discontinuation safe
• Median time to stent thrombosis is only 7 days when both antiplatelet agents are withheld 1
• Continuing aspirin while stopping ticagrelor provides essential protection against stent thrombosis 1

Monitor for recurrent bleeding 1:

• If major bleeding recurs despite aspirin monotherapy and PPI, consider temporary aspirin discontinuation for 5-7 days maximum 1
• Resume aspirin as soon as hemostasis is achieved 1
• In patients with high cardiovascular risk and recurrent bleeding, clopidogrel may be considered as an alternative to aspirin after discussion with cardiology 1, 2

Pacemaker and Repatha Management

The pacemaker lead evaluation is appropriate given the substernal chest pain - verify lead placement with chest X-ray and correlate with device interrogation findings. The 89% atrial pacing suggests appropriate device function, but lead displacement can cause atypical chest symptoms.

For the Repatha (evolocumab) autoinjector issues:

• The 2024 ESC Guidelines recommend LDL-C goal <55 mg/dL (1.4 mmol/L) with ≥50% reduction from baseline for all CCS patients 1
• If autoinjector pens continue to malfunction, consider switching to pre-filled syringes or alternative PCSK9 inhibitors
• Ensure proper storage (refrigerated) and technique - bring malfunctioning pens to clinic to identify the problem

Common Pitfalls to Avoid

• Never discontinue both antiplatelet agents simultaneously - this dramatically increases stent thrombosis risk 1
• Never fail to prescribe a PPI - this is a Class I recommendation that significantly reduces GI bleeding 1
• Never stop aspirin for more than 7-10 days - thrombotic events cluster in this window 1
• Never restart ticagrelor after discontinuation for bleeding unless there is a new ACS event or high-risk PCI requiring DAPT 1