Hematuria Management in Patients on Antiplatelet Medications After Acute Coronary Syndrome: A Review of the Current Evidence and Recommendations

Hematuria is a frequent urological presentation, particularly in patients with significant cardiovascular comorbidities who receive dual antiplatelet therapy (DAPT) after acute coronary syndrome (ACS). Managing hematuria in this high-risk population poses a unique clinical challenge, requiring a careful balance between thrombotic and bleeding risks. This review summarizes current evidence and provides practical recommendations for the multidisciplinary management of hematuria in patients on antiplatelet medications following ACS. Relevant literature and international guideline recommendations from urology, cardiology, and emergency medicine were reviewed, focusing on diagnostic evaluation, hemodynamic assessment, modification of antiplatelet therapy, surgical considerations, and reversal strategies. The management pathway begins with a prompt assessment of hemodynamic stability, hematuria severity, and underlying cause. Conservative measures include catheterization, bladder irrigation, and correction of coagulation disorders. The diagnostic evaluation should not be delayed, as up to 24% of cases of visible hematuria in this population are due to malignancy. Antiplatelet management depends on bleeding severity and thrombotic risk: mild bleeding generally allows continuation of DAPT; moderate bleeding may warrant temporary cessation of aspirin; severe bleeding often requires de-escalation to monotherapy; life-threatening bleeding necessitates immediate discontinuation of all antiplatelets. Interventional options—ranging from endoscopic clot evacuation to selective arterial embolisation—should be tailored to the stability and cardiovascular risk of the patient. Resumption of antiplatelet therapy should occur as early as clinically feasible, ideally within 48 hours, with de-escalated regimens considered for patients with a high bleeding risk. Hematuria in post-ACS patients on antiplatelets requires an individualized, multidisciplinary approach to optimize hemostasis without compromising cardiovascular protection. Early diagnosis of underlying urological pathology is essential, and both bleeding severity and ischemic risk should guide antiplatelet modification therapy. Evidence supports early specialist involvement, adherence to structured risk-adapted protocols, and judicious use of conservative or interventional measures to improve outcomes.