Dual antiplatelet agent-induced spontaneous liver hematoma

To report a case of a spontaneous liver hematoma in a patient receiving dual antiplatelet therapy for 5 years after coronary stent implantation.

A 76-year-old man with coronary artery disease presented to the hospital with acute right upper quadrant pain. He had been taking clopidogrel 75 mg/day, a P2Y(12) inhibitor, and aspirin 81 mg/day for 5 years after having a drug-eluting stent (DES) placed. Given a drop in hemoglobin (from 13.0 g/dL to 8.6 g/dL) and elevated liver enzymes, subsequent studies were performed and revealed a large liver hematoma. Clopidogrel and aspirin were discontinued. Aspirin was restarted 1 month later; there was no recurrence of bleeding.

Current guidelines recommend that a P2Y(12) inhibitor and aspirin after DES implantation be given for at least 12 months. However, because of concern for late stent thrombosis, some clinicians encourage patients to continue taking dual antiplatelet therapy beyond this period as long as the risk of bleeding is low. An objective causality assessment suggested that the liver hematoma was possibly related to the combination of clopidogrel and aspirin. To our knowledge, this is the first report of a patient who developed a liver hematoma while on aspirin and clopidogrel. Some recent studies have shown that the use of dual antiplatelet therapy for longer than 12 months does not reduce the rate of myocardial infarction or death from cardiac cause compared with aspirin monotherapy.

It may be safer to maintain dual antiplatelet therapy for no more than 12 months after DES placement.