Management of Hematuria After Angioplasty in Patients on Triple Antithrombotic Therapy
Discontinue enoxaparin immediately, as parenteral anticoagulation should be stopped right after PCI, and continue dual antiplatelet therapy (aspirin and ticagrelor) unless bleeding is severe or life-threatening. 1
Immediate Action: Stop Enoxaparin
Parenteral anticoagulation (enoxaparin) should be discontinued immediately after any invasive procedure, including angioplasty. 1 This is a Class IIa recommendation from both the 2018 ESC/EACTS and 2020 ESC guidelines.
Enoxaparin has no role in post-PCI management and continuing it alongside dual antiplatelet therapy creates excessive bleeding risk without additional benefit. 2 The combination of therapeutic anticoagulation with DAPT substantially increases major bleeding by 40-50%. 3
Among antithrombotic agents, enoxaparin is associated with a 3% rate of fatal hematuria episodes, which is higher than most other agents. 4
Maintain Dual Antiplatelet Therapy (Aspirin + Ticagrelor) Unless Bleeding is Severe
For patients with ACS treated with coronary stent implantation, DAPT with aspirin and a P2Y12 inhibitor (ticagrelor) is recommended for 12 months unless there are contraindications such as excessive bleeding risk. 1 This is a Class I, Level A recommendation.
The decision to continue or modify DAPT depends on bleeding severity:
If Bleeding is Non-Severe (Hematuria Without Hemodynamic Instability)
Continue both aspirin and ticagrelor. 1 The risk of stent thrombosis in the early post-PCI period (especially within the first month) is extremely high and potentially catastrophic. 1
Do not give additional doses of anticoagulant while bleeding is active, but maintain DAPT. 1
Optimize local measures: ensure adequate hydration, monitor hemoglobin, and consider urologic consultation if hematuria persists. 5
If Bleeding is Severe (Hemodynamic Instability, Hemoglobin Drop ≥2 g/dL, or Requiring Transfusion)
Consider discontinuing ticagrelor and continuing aspirin alone. 1 For patients at high bleeding risk (e.g., PRECISE-DAPT ≥25), discontinuation of P2Y12 inhibitor therapy after 6 months should be considered, but in the acute setting with severe bleeding, earlier discontinuation may be necessary.
De-escalation from ticagrelor to clopidogrel may be considered as an alternative strategy for patients deemed unsuitable for potent platelet inhibition. 1 Clopidogrel has lower bleeding risk than ticagrelor when combined with aspirin. 6
If ticagrelor must be stopped due to life-threatening bleeding within the first 2 weeks post-PCI, the patient is at very high risk of stent thrombosis. 1 In such cases, consider bridging with IV reversible antiplatelet agents (tirofiban, eptifibatide, or cangrelor) after bleeding is controlled, though this is not standard practice and requires multidisciplinary consultation. 1
Critical Timing Considerations
The risk of stent thrombosis is highest in the first 30 days post-PCI, particularly in ACS patients with recent stent implantation, long stents, and proximal vessel location. 1 Discontinuing both antiplatelet agents in this period carries potentially catastrophic consequences.
Ticagrelor should be discontinued at least 3 days before elective surgery if interruption is necessary, but in the setting of active bleeding, immediate discontinuation may be required. 1
Common Pitfalls to Avoid
Do not continue enoxaparin post-PCI. 1 This is the most common error and directly contributes to bleeding complications. Crossover between UFH and LMWH is also not recommended. 1
Do not stop both antiplatelet agents simultaneously in the early post-PCI period unless bleeding is truly life-threatening, as this dramatically increases stent thrombosis risk. 1
Do not assume hematuria on antithrombotics is benign. Full urologic evaluation is warranted, as malignancy is found in approximately 24-25% of cases. 5, 7
Among antiplatelet agents, aspirin is 6.7 times more likely to cause hematuria than clopidogrel and 3.5 times more likely than ticagrelor, but ticagrelor causes more major bleeding events. 7 However, the thrombotic risk in early post-PCI period outweighs these bleeding considerations unless bleeding is severe.
Medication-Specific Bleeding Risk Profile
Warfarin poses the greatest overall risk for hematuria but is less likely to cause major hematuria, whereas novel agents like dabigatran are 198 times more likely to cause major hematuria compared to warfarin. 7
Oral anticoagulants have 9.6 times higher odds of causing hematuria compared to prophylactic parenteral anticoagulants. 7
Antiplatelet agents are 76 times less likely to cause hematuria compared to anticoagulants. 7