Management of minor bleeding from antithrombotics

Patients using an antithrombotic may be alarmed by "nuisance bleeding" OR nosebleeds, prolonged bleeding from a small cut, etc. This isn't typically serious or a reason to stop therapy. Share tips to prevent bleeding, such as using a saline spray to keep the nasal passages moist, an electric razor to avoid nicks while shaving and a soft toothbrush to prevent bleeding gums. FOR A NOSEBLEED, advise sitting upright, leaning FORWARD and pinching the nose shut at the soft spot below the bridge for 10 minutes. If bleeding persists, suggest 2 or 3 sprays of oxymetazoline (Afrin, etc) in the bleeding nostril and repeating the steps above.

For A CUT, recommend applying pressure with a clean, damp piece of gauze for about 15 minutes and elevating the cut above the heart if possible. If pressure isn't enough for superficial cuts, suggest applying an OTC hemostatic product as styptic pencil, WoundSeal, etc.

Advise patients to call their physician right away if bleeding persists beyond 30 minutes of home treatment or if they see unexpected blood in the urine or stool, when coughing or vomiting, etc. Use any bleeding as a cue to reassess antithrombotic benefits and risks and confirm the right indication, duration, and dose. For example, evaluate stopping aspirin for patients using it for PRIMARY cardiovascular prevention.

Consider whether combination regimens, such as an anticoagulant plus 1 or 2 antiplatelets can be stepped down. Aspirin 81 mg, for most patients, consider discontinuing aspirin at discharge (low thrombotic risk or high bleeding risk), or after four to six weeks (high thrombotic risk with low bleeding risk). Anticoagulant, indefinitely for atrial fibrillation patients. When switching to monotherapy, ensure anticoagulant dose is appropriate for atrial fibrillation indication. P2Y12 inhibitor (Plavix), for stable, event-free patients, one-year post-event or stent placement, continuing an antiplatelet is associated with increased bleeding risk, and may not provide additional thrombotic protection. Consider stopping the P2Y12 inhibitor at one year in most patients. For patients with low thrombotic risk or high bleeding risk, consider stopping the P2Y12 inhibitor after six months.

Ensure that anticoagulant or antiplatelet doses are adjusted if needed based on interactions, renal function, weight, etc. And ask about products that may increase bleeding risk such as NSAIDs, ginkgo, or garlic. Suggest alternatives or stopping.

References

• Tomaselli, G.F., and others (2020). 2020 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants. Journal of the American College of Cardiology, 76(5), pp.594–622. Available at: https://www.jacc.org/doi/pdf/10.1016/j.jacc.2020.04.053

  Steffel, J., Verhamme, and others (2018). The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. European Heart Journal, [online] 39(16), pp.1330–1393. Available at: https://academic.oup.com/eurheartj/article/39/16/1330/4942493

  Angiolillo DJ, Goodman SG, Bhatt DL, et al. Antithrombotic therapy in patients with atrial fibrillation treated with oral anticoagulation undergoing percutaneous coronary intervention. Available at: Circulation 2018;138:527-36

  Valgimigli M, Bueno H, Byrne RA, et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: the Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-thoracic Surgery (EACTS). Available at: Eur Heart J 2018;39:213-60