Management of Anticoagulants and Antiplatelets During GI Bleeding

Initial Management of Antiplatelet Therapy

The American Heart Association recommends that for patients on aspirin for primary prevention of cardiovascular events, aspirin should be permanently discontinued as the bleeding risk outweighs cardiovascular benefit 1
For patients on aspirin for secondary prevention, the European Society of Cardiology recommends temporarily withholding aspirin only during active serious or life-threatening bleeding, and restarting as soon as hemostasis is achieved 2, 1
The American College of Cardiology recommends that for patients on dual antiplatelet therapy (DAPT), both agents should not be withheld simultaneously due to high risk of stent thrombosis 2, 1
In patients on DAPT with aspirin and clopidogrel, the American Heart Association recommends continuing aspirin and temporarily withholding clopidogrel during active bleeding 2, 1

The American College of Chest Physicians recommends that for patients on direct oral anticoagulants (DOACs), therapy should be interrupted at presentation with GI bleeding 1, 3
For patients on warfarin with serious bleeding, the European Society of Cardiology recommends using prothrombin complex concentrate (PCC) and low-dose vitamin K for urgent reversal rather than fresh frozen plasma 2

The American Heart Association recommends that for aspirin used for secondary prevention, aspirin should be restarted as soon as hemostasis is achieved 1
For P2Y12 receptor inhibitors, the European Society of Cardiology recommends resuming within 5 days after endoscopic hemostasis, and for ticagrelor, consider earlier resumption within 2-3 days due to its reversible binding 1, 2
For patients on warfarin, the American College of Cardiology recommends considering low molecular weight heparin bridging at 48 hours after hemostasis for high thrombotic risk, and restarting warfarin at 7 days after bleeding has stopped for low thrombotic risk 3
For DOACs, the American College of Chest Physicians recommends considering restarting treatment at a maximum of 7 days after bleeding has stopped 1

The European Society of Cardiology recommends that high thrombotic risk factors requiring earlier antiplatelet resumption include recent coronary stent placement, left main coronary artery stenting, proximal left anterior descending (LAD) artery stenting, last remaining patent coronary artery, multiple stents or long stent length, and history of stent thrombosis 4, 5, 6

The American Heart Association recommends initiating high-dose proton pump inhibitor (PPI) therapy for all patients with GI bleeding on antithrombotic therapy, and continuing PPI therapy for the duration of combined antithrombotic therapy 4, 7, 1
The European Society of Cardiology recommends considering PPI therapy even when a single antithrombotic agent is used, based on individual GI bleeding risk 5, 6

The American College of Cardiology recommends avoiding unnecessarily prolonged discontinuation of antiplatelet therapy, especially aspirin for secondary prevention, as discontinuation is associated with a nearly sevenfold increase in risk for death or acute cardiovascular events 1
The American Heart Association recommends being aware of potential drug-drug interactions between PPIs and clopidogrel, particularly in Asian populations with high prevalence of CYP2C19 slow metabolizers 2, 1