Optimal antiplatelet therapy for patients after antiplatelet therapy-induced gastrointestinal bleeding: when to resume?

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Abstract Background Adjusting antiplatelet strategies after antiplatelet-associated gastrointestinal bleeding (GIB) is a complex clinical challenge. there is no uniform answer to the question of when it is safe to restart antiplatelet therapy after GIB. Objective To assess the risk of outcomes at different times of resumption of antiplatelet therapy and explored the optimal time to resume therapy. Methods The study analyzed consecutive patients with antiplatelet-associated GIB from our hospital information system between October 2019 and June 2022. The primary outcomes were recurrent bleeding, major adverse cardiovascular and cerebrovascular events (MACE), and all-cause death. Multivariate-adjusted Cox proportional hazards models were used to evaluate the risks of these outcomes. The receiver operating characteristic curve was used to find the optimal time to resume treatment. Results Of the 617 patients with GIB after antiplatelet therapy successfully followed up, the median follow-up was 246 (interquartile range: 120–466) days, The mean age was 68.38 ± 10.68 years, 70.99% were male, and the age-adjusted Charlson comorbidity index score was 7.16 ± 1.96 points. Most patients (87.36%) interrupted therapy after GIB and 45.22% resumed within 90 days, of which 35.13% resumed within 7 days and 64.87% resumed after 7 days. Resumption therapy had a low risk of recurrent bleeding (uninterrupted as a reference: HR 0.32, 95% CI 0.15–0.67, p = 0.003), MACE (no resumption as a reference: HR 0.66, 95% CI 0.45–0.98, p = 0.037), and all-cause death (no resumption as a reference: HR 0.18, 95% CI 0.08–0.40, p＜0.001). And resuming therapy within 7 days had a lower risk of MACE (HR 0.18, 95% CI 0.08–0.44, p＜0.001) than after 7 days without a significantly higher risk of re-bleeding. The optimal time point for resuming therapy in this study was 9 days. Conclusion Resuming antiplatelet therapy after GIB provides a higher net clinical benefit. Early resumption of antiplatelet therapy (<7 days) significantly reduces the risk of MACE events. Although the risk of re-bleeding is increased, it is not statistically significant and has good clinical benefit. After analyzing the composite endpoint events, 9 days might be the optimal time to resume therapy for the antiplatelet population, especially for the single antiplatelet population. Our study provides new clinical data for the antiplatelet population after GIB to help physicians make better clinical decisions.