by Carolyn Thomas ♥ Heart Sisters on Blue Sky
Back in 2006, the New England Journal of Medicine published a study that compared ways to reduce the future risk of blocked coronary arteries in heart patients like me.(1) In this randomized, double-blind, placebo-controlled clinical trial (translation: research that can produce reliably high-quality evidence), over 15,000 people from 32 countries were studied.
By the way, it’s worth pointing out a fun fact here: the study published in the NEJM was a remarkable example of recruitment success. It turns out that up to 85% of all clinical trials in medicine fail to recruit or retain a sufficient sample size of participants, leading to “failure to meet research targets in 4 out of 5 trials” – even though nearly $1.9 billion is spent on participant recruitment annually.(2)
All of the participants recruited for this 2006 study had either documented cardiovascular disease or were at high risk for a cardiac event in the near future. Researchers followed up participants for over two years, monitoring which of the two options listed below was safer and more effective in reducing the risk of future coronary blood clots:
- taking the antiplatelet drug called clopidogrel (brand name: Plavix) along with a low-dose aspirin every day, or
- taking only the low-dose aspirin.
The British Heart Foundation offers this simplified reason that antiplatelet drugs are commonly prescribed to heart patients: “Antiplatelet drugs can reduce the chance of a heart attack because they prevent abnormal clotting in the arteries by telling platelets in the blood not to form a dangerous blood clot.”
Prescribing this particular combination of two antiplatelet drugs to patients is commonly known as dual antiplatelet therapy, or DAPT. It combines low-dose (81 mg) aspirin with another antiplatelet drug that can help prevent blood platelets from sticking together. Besides Plavix, other commonly-recommended antiplatelet drugs used in DAPT include the P2Y12 family of drugs like prasugrel (brand name: Effient) or ticagrelor (brand name: Brilinta).
According to Cleveland Clinic experts, cardiologists often prescribe DAPT for people who’ve had one or more of the following cardiac events or procedures, and are thus at higher risk for a serious cardiac event:
- heart attack (myocardial infarction)
- stroke
- mini-stroke (transient ischemic attack, or TIA)
- coronary artery bypass surgery (which reroutes blood around a blocked artery)
- angioplasty (a procedure to widen an artery using a tiny balloon)
- stent placement (to help keep that newly widened artery open)
In 2008 (two years after that big study in the NEJM came out), I was recuperating from a misdiagnosed heart attack and an emergency trip to the hospital’s cath lab, where a shiny stainless steel stent had been permanently implanted into my Left Anterior Descending Coronary Artery (one of the largest arteries bringing oxygenated blood to heart muscle cells, and also most often the culprit artery in heart attacks).
And because I now had this little foreign object living inside, I was also immediately warned that I’d need to be on DAPT (Plavix plus low-dose aspirin) every day for at least 12 months in order to help prevent another blockage forming inside either my new stent or a different coronary artery. Before being discharged from the C.C.U. (the intensive care unit for heart patients), one of the cardiac nurses even strapped a metal medic alert bracelet onto my wrist to wear home. It was engraved: “DO NOT STOP PLAVIX.”
That one-year minimum DAPT recommendation had been in place for some time by then, although newer studies (like this one published just last year in the journal Interventional Cardiology by University of California Irvine researchers) have reported “a new era of short-term DAPT therapy to reduce the incidence of major bleeding events.”(3)
“Major bleeding events?” The C.C.U. nurses forgot to mention before my hospital discharge any major bleeding events associated with taking my new antiplatelet meds.
Here’s more on that bleeding risk, from Cleveland Clinic cardiologists again:
“People taking DAPT are at risk for bleeding complications. The most common type of bleeding is gastrointestinal bleeding. Rarely, people on DAPT can experience bleeding inside their skull. In addition, people taking DAPT can bleed excessively after a fall or a cut.”
My own first exposure to “bleeding excessively“ while on DAPT after hospital discharge was during a pedicure appointment a few weeks after I came home. This“Congratulations! You Survived!” nail salon gift certificate from my family was intended to be a relaxing little break after the stress of a misdiagnosed widow-maker heart attack.
But with almost every touch of my salon tech Kim’s cuticle trimmer, bright red blood began seeping from each toe. It was alarming – for both of us! After a few toes, we agreed to immediately stop what, until that moment, I’d expected to be a lovely relaxing hour in the salon’s massage chair. “Let’s re-book for another day!” Kim whispered as she tried to scoop up and hide the bloody Kleenex tissues from the eyes of nearby clients.
Bruising – big dark technicolour purple and blue all-over bruising – is another very common side effect of DAPT.
One morning in the shower, for example, I noticed two perfectly round side-by-side dime-sized dark bruises just above my navel. How on earth did I get those two identical bruises there? The mystery was solved very quickly the next time my cat Lilly leaped onto my lap and “made biscuits” on my abdomen before settling down for a snooze. Those scary bruises had come from the tiny pushing paws of a 3-pound kitten!
Current treatment guidelines from the American College of Cardiology, the American Heart Association, and the European Society of Cardiology have tried to determine that sweet spot between reducing risks of future blood clots in coronary arteries while at the same time reducing risks of significant bleeding problems.
Those guidelines generally recommend a standard DAPT duration of six months for stable coronary artery disease (cardiac symptoms that tend to come on with exertion and go away with rest) and 12 months for acute coronary syndrome (unstable angina or heart attack).
Now here’s why the timing of those studies I mentioned is interesting to me:
Back in 2006, the conclusion of those researchers was that overall, Plavix plus aspirin was not significantly more effective than aspirin alone in reducing the rate of heart attack, stroke, or death from cardiovascular causes.
This study, of course, came out long before last year’s study was published by the California researchers. And many other studies (on how long/how much/which drug) have also been undertaken by academic cardiologists and their sleep-deprived grad students during those decades.
The Cochrane Heart Group is an international non-profit organization that updates its reviews on academic research to reflect findings of new medical evidence when it becomes available. In 2017, in an update to their 2011 review, Cochrane researchers illustrated why determining that DAPT sweet spot is so important:
“Overall, we would expect 13 myocardial infarctions (heart attacks) and 23 ischaemic strokes would be prevented for every 1,000 patients treated with the DAPT combination in a median follow‐up period of 12 months, BUT nine major bleeds and 33 minor bleeds would be caused during a median follow‐up period of 10 and 6 months, respectively.
“The results showed that there is a benefit of adding an antiplatelet drug to aspirin in terms of reducing the risk of heart attack or stroke. However, there is a higher risk of major and minor bleeding associated with this. There was no effect on death due to heart problems or death from any cause.”
Are you confused yet? Remember, dear heart sisters: every patient is different – your cardiologist will offer the most effective treatment recommendations based on your own unique situation.
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1. Clopidogrel and Aspirin versus Aspirin Alone for the Prevention of Atherothrombotic Events”. NEJM. 354:1706-1717. April 20, 2006
2. Idnay B et al. “Uncovering key clinical trial features influencing recruitment.” Journal of Clinical and Translational Science. September 4, 2023. 7(1):e199.
3. Tang KS et al, “Shortened Duration of Dual Antiplatelet Therapy Following Percutaneous Coronary Intervention: A Contemporary Clinical Review”. Interventional Cardiology. 18-31. December 11, 2023.
♥
Q: Were you surprised by bleeding or bruising side effects of your own antiplatelet drugs?
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NOTE FROM CAROLYN: I wrote more about our cardiac meds in my book, A Woman’s Guide to Living with Heart Disease (published by Johns Hopkins University Press). You can ask for it at your local library or favourite bookshop (please support your independent neighbourhood booksellers!) or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from Johns Hopkins University Press (use their code HTWN to save 30% off the list price).
Heart Sisters 
Hi Carolyn,
Thank you for all the work you do keeping your readers informed. This blog struck a chord with me.
I had triple bypass surgery in 2010. Since then, among other drugs, I’ve taken baby aspirin.
In 2015, I was enrolled in a study to compare baby aspirin with Rivaroxaban (Xarelto). It was a blind-blind study involving cardiac patients who were at least 5 years post-surgery. You received one or the other or both. I figured I was on both as I had an increase in nosebleeds and worse bruising.
The study was supposed to last 5 years; but was stopped early as the results had already shown that using both drugs decreased the number of cardiac “events”.
I remained on both until the spring of 2022 when I slipped on ice and banged my head. I ended up with a concussion caused by bleeding. I spent 3 days in the hallway in ER as they monitored my bleed with CT scans.
Two ER doctors questioned why I was taking two blood thinner drugs when I didn’t have A-fib. I was taken off both for a month and then resumed my baby aspirin. After consulting with my cardiologist, I’ve remained off the Xarelto. My nose bleeds have stopped and my bruising has lessened.
Last March, five months after surgery for breast cancer, I developed a large hematoma in my breast. My surgeon doesn’t want me to stop my baby aspirin as the hematoma isn’t life-threatening. Although it is somewhat smaller, it is still quite large. I’m thankful that I’m not taking Xarelto as that would likely have made this situation even worse.
Sincerely,
Linda
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Hi Linda – really interesting series of adventures you’ve had with your two blood thinners (aspirin = an antiplatelet blood thinner that helps keep blood platelets from sticking together to form blockages, and Xarelto = an anticoagulant blood thinner that helps slow down the blood’s clotting process).
I’m not a doctor so of course cannot comment specifically on your experience, except to generally say it can be frustrating for heart patients when treatment recommendations from doctors (each with the letters M.D. after their names!) are not on the same page (e.g. YES, Xarelto is often prescribed for Atrial Fibrillation as those 2 E.R. docs discussed, but as the drug’s manufacturers (Janssen, Bayer) point out, it’s also prescribed along with low-dose aspirin for coronary artery disease to help protect against blood clots that may cause a heart attack, stroke, or death.
That must have been shocking to develop that hematoma on your breast! No wonder you feel relieved not to be taking Xarelto now. Please take care. . . ❤️
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Hi Carolyn,
Firstly, your book has been an absolute lifesaver for me! I had a very similar experience to yours 6 weeks ago and have been struggling with the lack of information available and the amount of research I have had to do on my own.
I live in Nanaimo, so had to be transported to the cath lab in Victoria. I am currently on DAPT and my biggest problem has been nosebleeds that occur at night and last upwards of 3-4 hours. It was very frightening the first time it happened with so much blood and not much sleep. It has certainly slowed down my recovery!
I appreciate your blog and all of the experience and compassion that you share – knowledge is power!
Yours in good health,
Natascha
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Hello Natascha and thank you for your kind words about my book.
Your nosebleed experience is very distressing. Research based on the study called TRIUMPH, published in the Journal of the American College of Cardiology described what you’re going through as “Nuisance bleeding” (defined by the study authors as bruising, gum bleeds or nose bleeds that do not cause the patient “to seek medical care by a healthcare professional or hospitalization, and is not actionable but may still be significant from patients’ perspective.”)
This kind of academic bafflegab makes me insane. “MAY BE significant?” Only somebody who has never lost sleep, night after night, due to 3-4 hours of scary nosebleeds would say that this issue MAY be significant to heart patients, who are already overwhelmed by adjusting to their cardiac diagnosis. The authors suggest that these “adverse patient experiences, which are largely ignored in clinical trials, may be important issues in clinical practice” and add:
“Approximately 40% of patients reported nuisance bleeding in the year after their myocardial infarction (heart attack). There was a strong, independent association between post-discharge nuisance bleeding and DAPT use. Moreover, such nuisance bleeding was associated with a significantly worse quality of life.”
The study also found that many patients will stop DAPT entirely because of how this nuisance bleeding affects their quality of life. But that decision can cause worse problems – e.g. increased risk of future blocked arteries.
Far better to contact your cardiologist right away to discuss the possibility of adjusting your DAPT dosage levels.
Good luck to you. . .❤️
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Hi Carolyn,
After receiving a stent in my LAD in 2015 (and another in 2016) I was put on Brilinta for 12 months, as you describe here. (I am now on aspirin and Xarelto, and my husband with different cardiac issues is on Eliquis without aspirin, two similar and very expensive medications.) I did bruise easily on Brilinta (I called them my Brilinta bruises) and I also bruise fairly often on Xarelto but I don’t think as badly. Finding a bruise no longer surprises me.
What I remember most though is that within a month after receiving the first stent, I had terrible chest pain one night, and 3 doses of nitro pills had no effect on it. In a panic we went to the ER where I am glad to say that once I mentioned I was a new heart patient, they took me seriously despite my being female and whisked me right into a room and started an EKG right away. After testing and scanning it turned out to be not my heart but my gallbladder, where they said I have a “large” gallstone.
They confirmed this diagnosis by having me drink a concoction of a liquid antacid laced with lidocaine, which numbed the pain (I thought this was pretty clever, actually, even though not a great thing to have to swallow down!) What a relief to find out it was not my heart!
So I consulted with a surgeon — but then began a weeks-long back-and-forth between doctors as my cardiologist refused to allow me to go off the Brilinta for the surgery, which was then never done. It was really frustrating — I had several bouts of pain in the weeks that followed. Eventually my gallbladder calmed down and hasn’t bothered me since, but the gallstone is still in there and I suppose it could act up again.
I have been able to go off the Xarelto for 4 other surgeries in the past year with no problems. It’s great to have a healthcare team but frustrating when there is a conflict, or, like in the past 3 months with a new diagnosis of breast cancer, when all of them suddenly wanted me to do something for other issues (do physical therapy, wear a heart monitor for a month, have a dental filling done which then became infected, etc) when I was already completely overwhelmed. But overall I’m happy with the healthcare I receive and I’m doing very well.
God bless! ~~ Meghan
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Hi Meghan – It seems to me that although many of these antiplatelet drugs work similarly to prevent blood clots, studies suggest that the side effects may not be similar. Interesting that you were able to temporarily discontinue your Xarelto for four other surgeries in the past, but your cardiologist was worried about stopping your Brilinta for your gall bladder surgery.
It’s unfortunate that you had to suffer “several bouts of pain” while the gall bladder issue settled down. On top of that, considering your pain, breast cancer diagnosis, infected tooth – no wonder you were feeling so overwhelmed. I hope you are doing much better and won’t be facing more surgery any time soon!
Take care. . . ❤️
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In December 2017, I was placed on Warfarin – A blood thinner that blocks Vitamin K (I think??) not platelets.
The cardiac electrical physiologist recommended life long anti coagulation because of PAT and atrial flutter.
Two weeks later I developed chest pains and required a stent for an 80% blockage. Because I was already on warfarin for life, they placed a bare metal stent instead of a drug eluding stent (DES)and only recommended 30 days of DAPT added to the warfarin.
Triple anti coagulation!! I was purple with bruises from head to foot.
Now, years later, I remain on Warfarin and aspirin. Having a trip fall fracture of my arm created huge amounts of bleeding into my arm along with a new bruise for every IV and Blood draw. It is 5 weeks post fall and the bruises have still not fully resolved.
Being on Warfarin, before any procedure, colonoscopy, steroid joint injection etc I have to go off the Warfarin for 5 days to prevent excessive bleeding.
Recently, I asked my cardiologist about going off of the warfarin for good since I have had no episodes of atrial fibrillation but he quoted some convincing statistic about my risk because of Hypertrophic Cardiomyopathy (HCM) so I guess I will stay on it for life. The Risk vs Reward dilemma seems to be a part of every medical decision we must make.
My greatest fear, even over a myocardial infarction, is a stroke. And a stroke can be caused by either a clot or a bleed. . . So rock and a hard place LOL
P.S. It is Saturday today, right?
Have a beautiful day!
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Hello Jill – YES, it IS Saturday today, although I guess I didn’t realize it until a friend picked me up this morning to drive up-island and said: “You posted your Sunday article early this weekend!” Ooops!
Those triple anticoagulation bruises sound brutal – but also a sign that the meds were doing their job. I recall reading something about hospitals giving I.V. Vitamin K to patients on warfarin who need urgent surgery.
I sure hope your arm is healing uneventfully. I agree 100% with your “Risk Vs Reward dilemma” comment – for all medical decisions! I also agree with your assessment of stroke risks (clot vs bleed = which would you rather have?!?!)
Take care. . . ❤️
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