A 76-year-old woman comes to the emergency department vomiting blood. Her hematocrit has decreased from 31% to 21%. The patient has nonvalvular atrial fibrillation, stable coronary disease, and a non-ST-elevation myocardial infarction several years ago that was managed conservatively without a stent. She is on a direct oral anticoagulant (DOAC) and aspirin. A gastroenterologist wants to scope the patient, and a hospitalist is consulted to manage the bleeding as well as her antithrombotic therapy.

For Chi-Cheng Huang, MD, a hospitalist with Atrium Health Wake Forest Baptist and clinical adjunct associate professor of internal medicine at Wake Forest School of Medicine in Winston-Salem, North Carolina, the call is not close.

“Since this patient has stable coronary artery disease, the aspirin should be held in the setting of bleeding,” he said. The DOAC stays. Her CHA₂DS₂-VASc score is 6, and the embolic risk is real. The aspirin, layered on years earlier, now mostly feeds the bleed.

Patients like her show up often — people who are still taking both an anticoagulant and an antiplatelet agent, long after the reason for combining them has passed. For many such patients, the only effect of their concurrent use is an increased risk for bleeding. A hospital stay is one of the few opportunities for clinicians to thoroughly evaluate a patient’s entire regimen, and a new study suggests a coordinated program can catch these cases more consistently.

What the Study Tested

A 2026 JAMA Internal Medicine report evaluated a multilevel antithrombotic stewardship program run across the Veterans Health Administration (VHA). Seven VHA systems adopted the intervention; 128 served as control sites. Using a comparative interrupted-time-series design spanning July 2020 to July 2023, the researchers tracked antiplatelet use among outpatients already prescribed a DOAC.

The intervention arrived in two phases: 9 months of clinician and patient education plus electronic health record (EHR) modifications, followed by 16 months in which a pharmacist-facing alert was built into a widely used clinical dashboard to flag patients on concomitant antiplatelet therapy. 

At baseline, 26.1% of DOAC patients at intervention sites were also on an antiplatelet, compared with 30.1% at control sites. After rollout, antiplatelet use fell significantly faster where the program ran: an additional 0.58-percentage-point drop every 6 months. The early education and EHR changes and the later pharmacist flag contributed about equally. The effect was largest in patients with stable coronary artery disease, where antiplatelet use dropped by an extra 2.1 points every 6 months, enough to help about 1 in 18 eligible patients stop the antiplatelet. The authors estimate one major or clinically important bleed prevented for every 12 patients who safely stop it, over roughly 2 years.

The trial ran in the outpatient setting, not on an inpatient service, but the same approach applies on the wards.

Why Dual Therapy Outlasts Its Purpose

“I see this scenario frequently in hospital medicine,” said Gail Clifford, MD, an internal medicine physician and hospitalist at Paramount Wellness Retreat in Haddam, Connecticut. Most often, she said, the patient has atrial fibrillation and either a recent coronary stent or known coronary disease. “Often, by the time the patient is admitted for something unrelated months or even years after their initial treatment, we cannot easily understand the rationale for using both drugs at one time.”

One pattern Clifford flags among patients kept on dual therapy too long is “the reluctance of each physician to discontinue a medication that has been prescribed by another physician.”

Shamail Tariq, MD, an interventional cardiologist at Providence St. Jude Medical Center in Fullerton, California, sees the same problem from the cardiology side.

“The most common reason combination therapy continues longer than intended is unclear documentation or lack of clarity about the original indication and intended duration,” he said. “There are often several physicians involved, from the hospitalist or intensivist to the interventional cardiologist, general cardiologist, and primary care physician, so it’s easy for everyone to assume someone else is managing the medications.”

Reassessment at the Bedside 

None of the three experts framed this as a job for hospitalists alone. Clifford described reassessment as a collaborative effort between the hospitalist and the relevant specialist, usually cardiology. Tariq shifted the emphasis from who decides to how often. “This isn’t a one-time decision. It’s something that should be reassessed at every encounter as the patient’s risks and clinical situation evolve.”

An admission is one of those encounters, and often the one where a buried regimen finally surfaces.

When they reassess, bleeding risk comes first.

“Prior bleeding is probably the biggest predictor of future bleeding,” Tariq said. “Beyond that, I look at age, kidney function, anemia, concomitant medications, fall risk, and overall frailty.”

Clifford’s list overlaps closely, and also includes failure to reconcile the medication list across every provider involved. Huang reaches for two validated tools, HAS-BLED and CHA₂DS₂-VASc, and a frank conversation with the patient about the tradeoff. The goal, Tariq said, is “to tailor the regimen to the patient’s current risks rather than simply continuing the same medications indefinitely.”

“The biggest breakdown occurs during transitions of care,” Tariq said. “Discharge paperwork almost always includes what medications to start, but it doesn’t always specify how long they should continue or when they should be reassessed.”

Huang was blunt about why. “Due to the complexity of medicine and managing greater than 20 patients on a daily basis, discharge medication reconciliation is not done with the utmost focus,” he said. “Home medications prior to admission are added to the new medications during the hospitalization and at times continued simultaneously at discharge.”

What Hospitalists Can Take From It 

“No single intervention solves this problem,” Huang said. The approach he points to is “patient/clinician education along with a pharmacist-led, multicomponent collaborative effort.” That is close to what the VHA program did, and it worked best when the education, the EHR changes, and the pharmacist flag were all in place.

The fixes the three propose all put the question into the record instead of into memory. Tariq would document an anticipated stop date, “or at least a follow-up plan to review whether the indication still exists.” Clifford would make the indication and planned discontinuation date as visible as the drug name itself, so the medication list answers three questions: “What is the patient taking? Why are they taking it? And at what point should this combination be considered again?”

That changes what the job is. Catching every stray antiplatelet was never going to come down to one clinician’s memory. It comes down to whether the admission is built to catch it at all.

No disclosures were reported.