Bleeding outcomes of a stepped antiplatelet management pathway in coronary heart disease patients receiving dual antiplatelet therapy undergoing ercp stone extraction: a retrospective before–after study

Patients with coronary heart disease receiving dual antiplatelet therapy (DAPT) who undergo endoscopic retrograde cholangiopancreatography (ERCP) stone extraction face competing bleeding and thrombotic risks, while evidence for standardized perioperative antiplatelet management is limited. We evaluated the association between a stepped antiplatelet management pathway and short-term bleeding and explored bleeding-related factors. This single-center retrospective quasi-experimental before–after study included 150 patients undergoing their first ERCP stone extraction between November 1, 2022, and October 31, 2025. The Pre and Post groups comprised 77 and 59 patients, respectively; 14 Wash-in cases were included in descriptive analyses only. The primary outcome was clinically significant bleeding within 7 days, and the safety outcome was a composite ischemic/thrombotic endpoint within 30 days. Firth logistic regression with multiple imputation was used to estimate adjusted associations. Clinically significant bleeding occurred in 9/77 patients (11.7%) in the Pre group and 4/59 (6.8%) in the Post group (adjusted odds ratio [OR], 0.63; 95% confidence interval [CI], 0.22–1.86; adjusted risk difference, − 4.91% points; 95% CI, − 14.53 to 4.72). Any bleeding occurred in 18/77 (23.4%) and 10/59 (16.9%) patients, respectively (adjusted OR, 0.71; 95% CI, 0.32–1.59). The 30-day composite ischemic/thrombotic endpoint occurred in 6/77 (7.8%) and 3/59 (5.1%) patients ( P = 0.731). Overall pathway adherence was 71.2%. Exploratory analyses showed directional associations of clinically significant bleeding with sphincterotomy, lower preoperative hemoglobin, INR ≥ 1.30, previous gastrointestinal bleeding, and TG18 severe cholangitis, but all adjusted 95% CIs included 1. The pathway showed preliminary feasibility in routine care and a nonsignificant downward trend in 7-day bleeding, without an observed signal of increased 30-day ischemic/thrombotic events. These preliminary, hypothesis-generating findings require prospective validation.