Clinical Review

Anticipating and managing bleeding complications in patients with coronary stents who are receiving dual antiplatelet treatment

BMJ 2011; 343 doi: (Published 21 July 2011) Cite this as: BMJ 2011;343:d4264
  1. Neeraj Bhala, Medical Research Council health of the public research fellow and specialist registrar in gastroenterology1,
  2. Jaspal S Taggar, specialist registrar and research fellow in general practice2,
  3. Praveen Rajasekhar, Northern Regional Endoscopy Group research fellow and specialist registrar in gastroenterology3,
  4. Amitava Banerjee, clinical lecturer in cardiovascular medicine4
  1. 1Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford OX3 7LF, UK and Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, OX3 9DU, UK
  2. 2Division of Primary Care, University of Nottingham, Queens Medical Centre, Nottingham, UK
  3. 3South Tyneside District Hospital, South Shields, UK
  4. 4University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK
  1. Correspondence to: N Bhala nijbhala{at}

Summary points

  • Cardiac catheterisation and insertion of coronary artery stents are common interventions in patients with coronary heart disease

  • Compared with bare metal stents, drug eluting stents are associated with lower rates of restenosis but may be associated with later vascular complications, such as in-stent thrombosis

  • Patients with coronary artery stents need multiple antithrombotic drugs at the time of insertion, including long term dual antiplatelets (such as aspirin and clopidogrel)

  • Antithrombotic drugs are associated with bleeding at vascular access sites, intracranially, and the upper gastrointestinal tract

  • Acute upper gastrointestinal bleeding is managed by patient resuscitation, endoscopy for diagnosis and treatment, and medical gastroprotectant treatments

  • The management of emergency bleeding complications in patients with stents requires a multidisciplinary approach to balance bleeding versus long term vascular risks

Coronary artery stents are used to treat the full spectrum of coronary heart diseases, from stable angina through to ST elevation myocardial infarctions, and stent insertions are common medical procedures, with more than 80 000 and 1.3 million performed in the United Kingdom and United States each year, respectively.1 2 Both bare metal stents and drug eluting stents, which release anti-proliferative drugs and reduce restenosis, are commonly used. Although drug eluting stents have been associated with lower rates of medium term vascular complications, such as revascularisation, there have been concerns about other rarer later vascular outcomes. Of particular concern is the apparent small absolute risk of in-stent thrombosis with drug eluting stents.

To prevent these vascular complications, treatment with multiple antithrombotic drugs, including dual antiplatelet treatment (such as aspirin and clopidogrel), is an important part of acute stent management. To reduce the risk of in-stent thrombosis, longer periods of dual antiplatelet treatment are needed for drug eluting stents than for bare metal stents. However, antithrombotic treatments are associated with an increased risk of bleeding, which can …

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