The decision to discontinue anti-platelet medications is a challenging one. Antiplatelet therapy is something I see everyday in practice. Aspirin and clopidogrel are the two most common medications I see utilized. What’s often the greatest challenge with these agents? For me, it’s assessing the risk versus benefit in patients who have had a significant bleeding event. Here’s 5 really important considerations that I think about.
- The first question I like to think about is the indication for use. Has this patient had 5 heart attacks? If they have had multiple cardiac events and only one or two bleeding events, you might lean toward leaving it alone and monitoring.
- What does the patient want? Are they concerned more so about bleed risk or a thrombosis type event? This is certainly a strong consideration as the patient may want to make that determination for themselves.
- Type and severity of bleed. If the bleeding event was a GI bleed and we can use GI prophylaxis, we might be less likely to discontinue an antiplatelet medication. Compare that to a life changing intracranial bleed and we may come to a different conclusion.
- Life expectancy. In geriatrics and long term care especially, it is imperiative to think about the probable life expectancy as well as the goals of therapy. In patients who’ve had a bleeding event, a limited life expectancy might lead you down the path of discontinuing for good.
- What do the hemoglobin and platelet levels look like? Have they been dropping or do they remain constant despite use of an antiplatelet medication.
- Other medications. Is the patient on an anticoagulant as well? Maybe they are on another NSAID for pain management that can impair platelet function?
What else would you think about?
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Eric, so what’t the latest on patients with a h/o stent placement and duration of DAPT? 12 months and de-escalate to mono ASA or Plavix. Or is the duration of DAPT less/beyond 12 months? Thanks.