In a patient who just underwent PCI with a drug‑eluting stent for acute coronary syndrome and now has severe esophagitis with hematemesis (high bleeding risk), when should dual antiplatelet therapy be stopped?

When to Stop DAPT After PCI in ACS with High Bleeding Risk

In a patient with ACS who underwent PCI with drug-eluting stent and now has severe esophagitis with hematemesis, discontinue the P2Y12 inhibitor immediately while continuing aspirin monotherapy, as the life-threatening bleeding risk outweighs the thrombotic risk after the initial critical period. 1

Immediate Management for Active Life-Threatening Bleeding

• Stop the P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) immediately when life-threatening bleeding occurs, particularly gastrointestinal hemorrhage that cannot be controlled with endoscopic intervention 1
• Continue aspirin 75-100 mg daily unless the bleeding source absolutely cannot be controlled, as discontinuing both antiplatelet agents simultaneously carries extreme risk of stent thrombosis 1, 2
• The 2024 ESC guidelines explicitly state that discontinuing both antiplatelet agents should only occur in life-threatening bleeding situations where the source cannot be treated 3

Minimum DAPT Duration Thresholds

The critical question is whether your patient has completed the minimum mandatory DAPT duration:

For ACS Patients (Your Scenario):

• Absolute minimum: 1 month of DAPT is required even in very high bleeding risk patients 1
• Standard minimum: 6 months of DAPT is recommended for most ACS patients 1, 3
• If the patient has completed at least 1 month of DAPT, stopping the P2Y12 inhibitor with continued aspirin is reasonable given the hematemesis 1
• If the patient has not yet completed 1 month, this represents a critical decision point requiring multidisciplinary consultation with interventional cardiology and gastroenterology 1

High Bleeding Risk Definitions:

Your patient clearly meets high bleeding risk criteria with active hematemesis from severe esophagitis 1

Algorithmic Approach to DAPT Cessation

Step 1: Determine time since PCI

• Less than 1 month: Extreme caution—consider continuing DAPT if bleeding can be controlled endoscopically 1
• 1-3 months: Stop P2Y12 inhibitor, continue aspirin 1
• 3-6 months: Stop P2Y12 inhibitor, continue aspirin 1
• Greater than 6 months: Stop P2Y12 inhibitor, continue aspirin 1

Step 2: Control the bleeding source

• Urgent upper endoscopy for esophagitis management 1
• Proton pump inhibitor therapy at high dose 1
• If bleeding cannot be controlled AND patient is within 1 month of stent placement, consider bridging with short-acting IV antiplatelet agents (cangrelor, tirofiban) only if bleeding can be temporarily controlled 4

Step 3: Resume antiplatelet therapy

• Restart aspirin as soon as hemostasis is achieved 1, 2
• Consider restarting P2Y12 inhibitor at lower intensity (clopidogrel instead of ticagrelor/prasugrel) once esophagitis heals if still within 6 months of ACS 1, 5

Critical Timing Considerations

The 2021 ACC/AHA guidelines specify that for ACS patients with high bleeding risk or overt bleeding on DAPT, discontinuation after 3 months may be reasonable (Class IIb recommendation) 1

The 2024 ESC guidelines are more aggressive, stating that for patients at very high risk of life-threatening bleeding, clopidogrel may be considered for only 1 month (Class IIb recommendation) 1

However, both guidelines emphasize that at least 1 month is the absolute floor for ACS patients 1, 3

Common Pitfalls to Avoid

• Never stop both aspirin and P2Y12 inhibitor simultaneously unless in extremis—this dramatically increases stent thrombosis risk which has 20-40% mortality 1, 3, 2
• Do not assume "stable" means safe to stop early—ACS patients remain at elevated thrombotic risk for 6-12 months 1, 3
• Avoid restarting potent P2Y12 inhibitors (ticagrelor, prasugrel) in patients with gastrointestinal bleeding history; use clopidogrel if P2Y12 inhibitor must be restarted 1, 5
• Do not delay endoscopic intervention while debating antiplatelet management—source control is paramount 1

Post-Acute Management

Once hematemesis resolves:

• Continue aspirin 75-100 mg daily lifelong 1
• Add proton pump inhibitor indefinitely given esophagitis history 1
• If within 6 months of ACS and esophagitis healed, consider restarting clopidogrel 75 mg daily (not ticagrelor or prasugrel) to complete closer to 6 months total DAPT duration 1, 5
• If beyond 6 months from ACS, aspirin monotherapy is sufficient 1