tough ? - ASA + Plavix + low PLTs

[josephf1]

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Pt is 60M with DES to LAD placed 6 mos ago on DAT.
Now presenting with hematuria, ARF 2/2 obstruction and sepsis.
Put on 4th gen cepah and develpoed pancytopnai (etiology ? but may include sepsis, BMS, MDS, ABX). Was on no heparin.
No urology wants to do cysto and bx to discover source of obstruction since CT showed nothing.
? is if PLTS are now 35, and procedure is several days away, would you stop ASA and/or Plavix.
When do you stop one/both or low platelets in general.
WOuld you transfuse platelets as needed and keep both on board for recent DES?
I know in stent thrombosis can have mortaltiy rates up to almost 50%.
Saw some data on some of this but nothing more official than it seems cards wants both meds kept unless major bleeding risk and surgery has to decide the risk. BUt I saw no data on low platelets except some case studies with ITP That had no bleeding on DAT.
THanks,

 

[dragonfly99]

35 is a pretty low platelet count (assuming no clumping, etc. and that it's a real platelet count).
Ideally you want Plavix and aspirin for a least a year after drug eluting stents. Risk of removing these is less after 6 months versus 1-3 months after stenting.

I don't think you'll find any large randomized trial (or any randomized trial) with patients in the exact same situation as yours. This is where the art of medicine comes in - clinical judgment and integrating all the information you have, the patient and family's wishes for his life, etc.

You have to balance the bleeding risk with the risk of stopping the aspirin or Plavix temporarily. Most urologists will not do procedures with the patient on Plavix.

 

[k96tw01]

you can assess the risk further if you have more info on the PCI.

what type of DES? lower rates of stent thrombosis with the Endeavour platforms.

what vessel was intervened upon? LMCA stent vs distal Diag3 = tremendously different amount of at risk myocardium

is this just blood-tinged hematuria, or true anemia producing hematuria? What I mean to get at is, does the pt have a degree of active bleeding / dropping Hgb such that you would consider stopping DAPT just on the basis of that, or is this purely out of consideration of the cysto (which can safely be preformed on DAPT in most cases)

If it looks like the balance of above is, not much myocardium at risk and the bleeding is truely profuse/dropping his hgb then 6 mos out is pretty safe on the ST front... especially with a ZES stent (Endeavour)