2025 Southeastern Residency Conference

Title: Rates of Gastrointestinal Bleeding (GIB) in Patients Taking Concomitant Dual Antiplatelet Therapy (DAPT) and SSRI/SNRI Therapy Within One Year of Acute Coronary Syndrome (ACS) 
 
Authors: Hannah Holbert, Thaddeus McGiness, A. Shaun Rowe, Travis Fleming


Objective: Evaluate potential gastrointestinal bleeding risk associated with combined SSRI/SNRI and DAPT in patients receiving these medications for twelve months post-ACS.


Self-Assessment Question: Which of the following was associated with increased rates of GIB in patients at 12 months post-ACS?  a. Aspirin + prasugrel + duloxetine; b. Aspirin + prasugrel + sertraline; c. Aspirin + clopidogrel + venlafaxine; d. Aspirin + ticagrelor + fluoxetine; e. None of the above  


Background: Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) modulate serotonin, which promotes mood enhancement in the central nervous system (CNS) and hemostasis in the peripheral nervous system (PNS). Inhibition of serotonin reuptake in the CNS increases emotional stability, making SSRIs and SNRIs useful antidepressants. In the PNS, these drugs prevent serotonin-mediated platelet aggregation, increasing bleeding risk. Because depression is common following major adverse cardiovascular events, there is a potential for patients to take concomitant SSRI or SNRI therapy with dual antiplatelet therapy (DAPT) for 12 months post-percutaneous intervention. The purpose of this study was to evaluate if patients receiving this combination were at a greater risk of gastrointestinal bleeding due to multiple antiplatelet mechanisms compared to those receiving DAPT alone. 
 
Methods: This single center retrospective cohort study included adult patients diagnosed with acute coronary syndrome (ACS) and treated with percutaneous intervention, stent implantation, and DAPT between January 1, 2014, to January 1, 2024. Patients were excluded from this study if they received DAPT for any indication other than ACS (e.g., ischemic stroke), if they had a previous diagnosis of cirrhosis, Helicobacter pylori infection, or cancer of the gastrointestinal tract, or if any of the following medications were on their discharge medication list: anticoagulants, systemic steroids, systemic non-steroidal anti-inflammatory drugs (NSAIDs), ginseng, garlic, ginkgo, or vitamin E. The primary outcome of this study was rates of gastrointestinal bleeding within 12 months of ACS diagnosis. Additional secondary outcomes included length of stay, therapy modifications at discharge, and 30-day and 90-day readmission rates.
 
Results: The primary outcome was observed in five patients (3%) in the DAPT group and no patients in the DAPT plus SSRI or SNRI group (P = 0.336). Readmission at 30 days occurred in 23 patients (13.6%) in the DAPT group and 10 patients (17.9%) in the DAPT plus SSRI or SNRI group (P = 0.436). Patients who were readmitted within 90 days of ACS discharge included 37 patients (21.9%) and 19 patients (33.9%) in the DAPT and DAPT plus SSRI or SNRI group, respectively (P = 0.071). There was no statistical difference between median length of stay between the two groups (P = 0.430). One notable baseline characteristic was a documented history of coronary artery disease (CAD). In the DAPT only group, the majority (106 patients; 62.7%) did not have a prior history of CAD, whereas 37 patients (66.1%) in the DAPT plus SSRI or SNRI group did have a documented history of CAD. This finding regarding past medical history of CAD was statistically different between both groups (P < 0.001). 
 
Conclusion: This study found no statistical difference in the rate of GIB in patients who received DAPT compared to those who received DAPT plus an SSRI or SNRI post-ACS. A statistical difference was observed, however, when comparing SSRI or SNRI use in patients based on prior history of CAD. Because patients with a prior history of CAD were more likely to take SSRIs or SNRIs, this study further endorses the use of these agents to treat secondary mental health disorders following ACS. Additionally, none of the patients in this study population who were taking SSRIs or SNRIs experienced a GIB, implying that use of these antidepressants could be considered both effective and safe in this population. More research should be conducted to further evaluate if the use of SSRIs or SNRIs in patients receiving DAPT for one-year post-ACS  impacts rates of bleeding events, especially in women, racial minorities, patients who underwent elective PCIs, and patients who experienced other types of bleeding events.