The risk of stopping antiplatelet therapy

Antiplatelets , especially Aspirin and Clopidogrel have established their importance in management of coronary artery diseases. But they also pose a bleeding risk. This risk is high if a procedure needing tissue sample is done. We had a 66 yo male ..4 months after a STEMI for which he received a drug eluting stent , and was started on Aspirin and clopidogrel. This clinic visit he is complaining of 6 month h/o early satiety, loss of apetite..and our records show a weight loss of 15lb in last 3 months.He needed a upper GI endoscopy ..with a possible biopsy. What do we do with his antiplatelets? ....Lets look at some facts from AHA

· Cessation of all antiplatelet therapies after PCI, at any time, for any stent, is associated with an increased risk of thrombotic events, including late stent thrombosis. These events are likely to occur within 7 to 30 days of drug discontinuation. 

·Cessation of clopidogrel (alone) during the early period after PCI (within 30 days of either DES or BMS placement) is associated with an increased risk of events. 

·Cessation of clopidogrel (alone) beyond 30 days from the time of BMS placement is common in clinical practice and does not confer increased risk of thrombosis over a brief period of time. 

·Cessation of clopidogrel (alone) upon completion of 6 months of treatment after DES placement is controversial (in terms of long-term risk) but does not seem to confer a significant short-term risk(within the subsequent 30 days) in a majority of patients if aspirin is continued. 

 The importance of continuing aspirin in the above scenarios was shown by a review in JACC 2005, where the median duration of stent thrombosis when both drugs were stopped, was 7 days...compared to 122 days when only clopidogrel was stopped and aspirin was continued.In addition, many retrospective studies have shown safety of continuing aspirin during GI procedures. The GI prcedures have been classified into high & low risk based on the risk of bleeding.

Considering the urgent need for endoscopy, the fact that UGI endoscopy is a low risk for bleeding, and the STEMI 4 months ago....we had our patient continue Aspirin, but stop Clopidogrel 5 days before procedure. He will continue his dual antiplatelet therapy the day after his procedure. As always.....the befits & risks were, and have to be discussed with the patient!