When to Start Antiplatelet Therapy in Patients with Hemorrhagic Stroke and Prior Percutaneous Coronary Intervention: A Clinical Challenge
Gleopatra D. Molle *
Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia.
Ardian Rizal
Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia.
*Author to whom correspondence should be addressed.
Abstract
Aims: This case demonstrates the challenges and complexities of managing antiplatelet therapy in the setting of ICH prior to elective PCI. The determination of when to restart antiplatelet therapy and which to use can be more difficult given the absence of clear guidelines due to lack of evidence.
Presentation of Case: A 45-year-old man developed ICH one week after PCI. He had a history of single-vessel coronary artery disease in the left anterior descending artery, which necessitated the implantation of a drug eluting stent. Imaging showed a small hemorrhage in the right lentiform nucleus and a chronic subdural hematoma. The patient, with a history of hypertension, was on dual antiplatelet therapy (DAPT) with aspirin and ticagrelor. Due to life-threatening bleeding, DAPT was temporarily stopped. After discharge, fear of stroke recurrence led to poor follow-up and medication noncompliance. Three months later, he presented with seizures, slurred speech, and weakness. Cardiac assessment showed no acute ischemia, and he was advised to resume DAPT and referred for stroke rehabilitation.
Discussion: This case highlights that management is not limited to acute hemorrhage but also includes the potential emotional consequences that can contribute to difficulties with adherence. Failure to comply with DAPT results in a very high thrombotic risk. Nevertheless, recent meta-analyses show that early reinitiation of antithrombotic drugs post-ICH decreases the risk of rebleeding with no increased incidence of ischemic events. A careful, multidisciplinary assessment is required to manage patient apprehensions and to plan reinitiation of therapy.
Conclusion: A lack of established guidelines for restarting antiplatelet therapy after PCI ICH drives home the need for teamwork and patient instruction. The round, well-considered re-challenge setting is important for preventing poor adherence and backward outcomes. The present case illustrates the need for evidence-based constructs to guide clinical practice based on research.
Keywords: Intracerebral haemorrhage, dual anti platelet therapy, percutaneous coronary intervention