Responses to nuisance bleeding and medication concerns when on Dual Antiplatelet Therapy

Background
Dual Anti-Platelet Therapy (DAPT) is prescribed for 12 months to all people who are diagnosed with acute coronary syndrome (ACS) (heart attack or unstable angina) or undergo coronary interventions (percutaneous coronary intervention, PCI; and coronary artery bypass grafting, CABG). An adverse side effect of DAPT is bleeding, including nuisance bleeding such as nosebleeds, bleeding from gums and excessive bruising. Nuisance bleeding may influence quality of life and lead to premature discontinuation of treatment; however, adherence to DAPT is crucial for preventing a second heart attack. Few studies have focused on patient experiences with nuisance bleeding when on DAPT, and little is known of patients’ attitudes towards adherence, their contact with healthcare professionals because of nuisance bleeding, and the outcome of such interactions.
The aim of this qualitative study was to understand (1) patient perspectives on adherence and nuisance bleeding when on DAPT, (2) help-seeking behaviours such as seeking information and accessing care, and (3) the outcome of DAPT-related patient-provider interactions.
Methods
This study took place in the South West of England. Post-coronary intervention (CABG or PCI) and pharmacotherapy only patients were invited to attend one of four focus group discussions: two with patients at the start (0-3 months) and two with patients coming to the end (9-12 months) of their DAPT treatment.
Individual semi-structured interviews with cardiologists, cardiac surgeons and general practitioners were conducted in parallel to explore clinician perspectives on DAPT prescribing and prescribing decisions in the context of nuisance bleeding.
Recordings were transcribed verbatim, anonymised, and analysed using framework analysis.
Results
Twenty-one patients (post-PCI, post-CABG, or pharmacotherapy only) attended the focus groups: nine were at the early stages (0-3 months), and 12 at the end (9-12 months) of their treatment. Only one woman attended the focus groups. The average age of participants was 66 years.
Six cardiac surgeons, six cardiologists and five GPs were interviewed over the phone or face-to-face.
For both patients and clinicians, being informed about the risk for nuisance bleeding, the importance of DAPT for reducing ischemic risk, and awareness of the short-term nature of treatment encouraged adherence and continuation with treatment. In patient narratives adherence and help-seeking behaviours were impacted on by (1) participants’ beliefs about their illness and treatment; (2) access to family support; and (3) perceived quality of care and care pathways, including timely and appropriate access to specialist care and medication counselling.
Clinician and patient narratives suggested patients rarely access medical care because of nuisance bleeding, and concerns with side effects and medications would most often be addressed by general practice. General practitioners saw themselves as generalists, and when faced with nuisance bleeding would not discontinue medication or make changes without guidance from a specialist. Patients recounting consultations with general practitioners reported frustration when their expectations of the outcome of the consultation were not met and would prefer direct access to specialists.
Implications
Findings indicate the crucial role of family-centred medication counselling at different stages in the patients’ treatment journey to address the dynamic and shifting nature of information needs between the time of diagnosis and surgical and/or pharmacotherapeutic intervention, and discharge into the community. The experiences of general practitioners and patients with DAPT medication management should be explored further to identify gaps in care and support needs.