Exclusion Criteria for Dual Antiplatelet Therapy in Elderly Patients

Absolute Contraindications

Active major bleeding at any site, tissue, or organ is an absolute contraindication to dual antiplatelet therapy 3
Uncontrollable active bleeding state requires immediate cessation of antiplatelet agents 3
Recent gastrointestinal bleeding within the past month significantly increases hemorrhagic risk and warrants avoidance 4
History of intracranial hemorrhage is a critical exclusion criterion, as dual antiplatelet therapy substantially increases recurrence risk 1, 2
Previous stroke with hemorrhagic component contraindicates this combination 5
Known bleeding disorders or severe thrombocytopenia preclude safe use 3

The European Society of Cardiology identifies advanced age (≥80 years) as a major risk factor for bleeding under antiplatelet therapy 6
Patients over 75 years were excluded from loading dose studies with fibrinolytic therapy due to bleeding concerns 7, 5
No loading dose of clopidogrel should be given to patients >75 years receiving fibrinolytic therapy 7, 5
Proton pump inhibitor co-prescription is strongly indicated if any of the following exist: history of gastrointestinal bleeding, chronic NSAID or corticosteroid use, age ≥65 years, dyspepsia or gastroesophageal reflux disease, or chronic alcohol use 2, 5, 6, 4
Severe renal impairment (creatinine clearance <30 mL/min) increases hemorrhagic complications with any antiplatelet regimen 3, 8
Monitor renal function at least annually, or 2-3 times yearly if moderate impairment exists 6

Triple therapy (aspirin + clopidogrel + oral anticoagulant) dramatically increases bleeding risk and requires specific protocols 1, 2
If oral anticoagulation is indicated, triple therapy should be limited to 1-6 months maximum, then transition to anticoagulant plus single antiplatelet agent 2
Ticagrelor and prasugrel are contraindicated as part of triple therapy—only clopidogrel should be used 2

Discontinue clopidogrel at least 5 days before elective surgery unless urgency for revascularization outweighs bleeding risk 9, 4
For CABG, withhold clopidogrel 5-7 days preoperatively 5

Calculate bleeding risk using PRECISE-DAPT score (available at www.precisedaptscore.com) 1
Score ≥25 indicates high bleeding risk, and high-risk patients should receive shortened DAPT duration (≤6 months) 1
HAS-BLED score ≥3 indicates high bleeding risk requiring careful consideration of dual antiplatelet therapy duration and intensity 1