Older woman on DAPT after NSTEMI: bleeding risk, surgery and a bleed — case discussion

Presentation

Practice case (not a real patient). A 77-year-old woman in Brisbane has an NSTEMI and PCI with a drug-eluting stent to the left anterior descending artery.^[1] Her eGFR is 48 mL/min and her haemoglobin is 12.6 g/dL; she has no atrial fibrillation, no previous bleeding, stroke or cancer, and no anticoagulant.^[2] She weighs 58 kg. She was discharged on aspirin and a P2Y12 inhibitor.^[1]

Step 1 — Which P2Y12 inhibitor, and is she HBR?

Discussion:

• She has two ARC-HBR minor criteria, age 75 years or more and moderate CKD (eGFR 30–59 mL/min); ACC/AHA 2025 says at least 1 major or 2 minor criteria helps to identify those at increased risk of bleeding.^[2]
• ESC 2023: in older ACS patients, especially if HBR, clopidogrel as the P2Y12 receptor inhibitor may be considered (Class IIb, Level B); the definition of older ranges from 70 to 80 years across trials.^[1]
• If prasugrel were chosen, ESC 2023 gives 5 mg once daily for patients aged 75 years or more or weighing under 60 kg.^[1]
• For older adults, ESC 2023 recommends adapting the choice and dosage of antithrombotic agent, as well as of secondary prevention medications, to renal function, co-medications, comorbidities, frailty, cognitive function and specific contraindications (Class I, Level B).^[1]

Step 2 — How long, and what protects the stomach?

Discussion:

• ESC 2023: a P2Y12 receptor inhibitor in addition to aspirin is recommended for 12 months unless there is HBR (Class I, Level A); she is HBR.^[1]
• ESC 2023: in HBR patients, aspirin or P2Y12 receptor inhibitor monotherapy after 1 month of DAPT may be considered (Class IIb, Level B).^[1]
• ACC/AHA 2025: in ACS patients undergoing PCI who are at high bleeding risk, transition to SAPT after 1 month may be reasonable to reduce bleeding risk (COR 2b, LOE B-R).^[2]
• NHFA/CSANZ 2025: in people discharged after ACS who are at low ischaemic and/or high bleeding risk, cease DAPT at 1–3 months after the ACS and continue SAPT (strong recommendation, high certainty).^[8]
• Among its suggested strategies to reduce bleeding risk related to PCI, ESC 2023 Table 7 lists PPIs in patients on DAPT at higher-than-average risk of gastrointestinal bleeds: a history of gastrointestinal ulcer or haemorrhage, anticoagulant therapy, chronic NSAID or corticosteroid use, or two or more of age 65 years or more, dyspepsia, gastro-oesophageal reflux disease, Helicobacter pylori infection and chronic alcohol use.^[1]

Step 3 — A cholecystectomy is needed

At 3 months she develops biliary colic, and an elective laparoscopic cholecystectomy is proposed. She is still on DAPT.^[7]

• ESC 2022 recommends delaying elective non-cardiac surgery until 6 months after elective PCI and 12 months after an ACS (Class I, Level A); her PCI was for an ACS.^[7]
• If the operation becomes time-sensitive, ESC 2022 says that in high-risk patients with a recent PCI (for example STEMI or high-risk NSTE-ACS), a DAPT duration of at least 3 months should be considered first (Class IIa, Level C).^[7]
• If P2Y12 interruption is then indicated, clopidogrel is withheld for 5 days (ticagrelor 3–5 days, prasugrel 7 days) (Class I, Level B), and aspirin is continued peri-operatively if the bleeding risk allows (Class I, Level B).^[7]
• ESC 2022 Table 9 lists cholecystectomy among surgery with low bleeding risk.^[7]
• Restarting antiplatelet therapy as soon as possible (within 48 h) after surgery, according to interdisciplinary risk assessment, is recommended (ESC 2022, Class I, Level C).^[7]

Step 4 — A bleed

At 5 months, before any operation, she is admitted with melaena; her haemoglobin is 8.8 g/dL.^[2]

• ACC/AHA 2025 Table 22, which gives the ARC-HBR criteria after PCI, lists spontaneous bleeding requiring hospitalisation or transfusion in the past 6 months, or at any time if recurrent, as a major criterion; her melaena is a spontaneous bleed that needed admission.^[2]
• ESC 2023 says bleeding is associated with a poor prognosis in ACS and is a major driver of unplanned DAPT discontinuation.^[1]
• On transfusion, ESC 2023 says no formal recommendation on the optimal strategy (liberal versus restrictive) in patients with ACS can be made at present, while ACC/AHA 2025 says that in patients with ACS and acute or chronic anaemia, transfusion to a haemoglobin of 10 g/dL or more may be reasonable to reduce cardiovascular events (COR 2b, LOE B-R).^[1][2]
• ESC 2023: a PPI in combination with DAPT is recommended in patients at high risk of gastrointestinal bleeding (Class I, Level A).^[1]

Learning points

• HBR is decided in a structured way: ESC 2023 says one major or two minor ARC-HBR risk factors indicate HBR, and ACC/AHA 2025 says at least 1 major or 2 minor criteria in its Table 22 helps to identify those at increased risk of bleeding.^[1][2]
• In HBR patients, aspirin or P2Y12 inhibitor monotherapy after 1 month of DAPT may be considered (ESC 2023, Class IIb, Level B); in ACS patients undergoing PCI who are at high bleeding risk, transition to SAPT after 1 month may be reasonable to reduce bleeding risk (ACC/AHA 2025, COR 2b, LOE B-R); in people discharged after ACS who are at low ischaemic and/or high bleeding risk, NHFA/CSANZ 2025 says to cease DAPT at 1–3 months after the ACS and continue SAPT (strong recommendation, high certainty).^[1][2][8]
• ESC 2022 recommends delaying elective non-cardiac surgery until 6 months after elective PCI and 12 months after an ACS (Class I, Level A), and restarting interrupted antiplatelet therapy as soon as possible (within 48 h) after surgery, according to interdisciplinary risk assessment (Class I, Level C).^[7]