A patient 7 days after cardiac catheterization on low‑dose aspirin (75 mg) and clopidogrel (75 mg) presents with a groin hematoma; how should antiplatelet therapy and activity be managed, including imaging and timing of clopidogrel restart?

Management of Groin Hematoma 7 Days Post-Cardiac Catheterization

Continue aspirin 75 mg daily without interruption, hold clopidogrel temporarily, and restart clopidogrel within 5 days once the hematoma is stable. 1

Antiplatelet Management

Aspirin (Continue)

• Do not stop aspirin for secondary cardiovascular prevention, even in the setting of bleeding complications 1
• Aspirin should be continued at the current dose of 75 mg daily throughout the hematoma management period 1
• Stopping aspirin significantly increases cardiovascular events and mortality (up to 10-fold increase in all-cause mortality when discontinued after bleeding) 1
• The median time to coronary stent thrombosis is only 7 days when both antiplatelet agents are withheld simultaneously 1

Clopidogrel (Temporarily Hold, Then Restart)

• Temporarily discontinue clopidogrel while the hematoma is actively expanding or symptomatic 1
• Restart clopidogrel within 5 days maximum to prevent catastrophic stent thrombosis 1
• When only clopidogrel is held (with aspirin continued), the median time to stent thrombosis extends to 122 days versus 7 days when both are stopped 1
• This 5-day window represents the optimal balance between hemorrhage risk and thrombosis risk based on drug-eluting stent studies 1

Imaging and Assessment

Initial Evaluation

• Obtain ultrasound imaging of the groin to characterize hematoma size, location, and presence of active bleeding 2, 3
• Assess for pseudoaneurysm or arteriovenous fistula, which may require intervention beyond conservative management 2
• Check hemoglobin/hematocrit to quantify blood loss and guide transfusion decisions 3

Monitoring Parameters

• Serial physical examinations to assess hematoma expansion (measure and mark borders) 2, 3
• Daily hemoglobin checks if hematoma is expanding or patient is symptomatic 3
• Monitor for signs of compartment syndrome: severe pain, paresthesias, pallor, pulselessness 3

Activity Restrictions

Immediate Management (Days 1-3 After Hematoma Discovery)

• Strict bed rest with affected leg immobilized to prevent hematoma expansion 2, 3
• No hip flexion beyond 30 degrees on the affected side 2
• Avoid Valsalva maneuvers (straining, heavy lifting, coughing without splinting) 3

Progressive Mobilization (Days 4-7)

• Begin gradual mobilization only after hematoma stabilization is confirmed (no expansion for 48 hours) 2, 3
• Start with sitting at bedside, then standing, then short-distance ambulation with assistance 2
• Continue to avoid strenuous activity, heavy lifting (>10 lbs), or activities requiring hip flexion >90 degrees 3

Return to Normal Activity (Week 2+)

• Resume normal activities gradually over 2-4 weeks based on hematoma resolution 2, 3
• Avoid high-impact activities until complete resolution documented by imaging 2

Critical Timing Considerations

Clopidogrel Restart Decision Tree

• If hematoma stable and not expanding at 48-72 hours: Restart clopidogrel on day 3-4 1
• If hematoma still expanding at 72 hours: Continue holding clopidogrel but must restart by day 5 regardless, as thrombosis risk exceeds bleeding risk after this point 1
• Consult cardiology urgently if considering holding clopidogrel beyond 5 days, especially if patient had acute coronary syndrome within 6 months or complex stenting 1

Common Pitfalls to Avoid

• Never stop both antiplatelet agents simultaneously – this dramatically increases stent thrombosis risk with median onset of only 7 days 1
• Do not give platelet transfusions – retrospective data shows no benefit in reducing rebleeding and association with higher mortality 1
• Do not exceed 5 days without P2Y12 inhibitor – the risk of fatal stent thrombosis outweighs bleeding risk after this timeframe 1
• Do not assume all groin swellings are simple hematomas – always image to exclude pseudoaneurysm or coexistent hernia 2

Gastrointestinal Protection

• Consider adding or continuing proton pump inhibitor (omeprazole 20-40 mg daily) given dual antiplatelet therapy and recent bleeding complication 1
• PPIs reduce ulcer-related bleeding risk in patients on antiplatelet therapy without compromising cardiovascular outcomes 1

Intervention Thresholds

Conservative Management Appropriate If:

• Hematoma <10 cm diameter 2, 3
• Hemodynamically stable 3
• No signs of compartment syndrome 3
• Hemoglobin stable or declining <2 g/dL 3

Consider Surgical/Interventional Management If:

• Rapidly expanding hematoma despite conservative measures 2, 3
• Hemodynamic instability or hemoglobin drop >2 g/dL 3
• Pseudoaneurysm identified on imaging 2
• Signs of compartment syndrome develop 3