Should baby (acetylsalicylic acid) aspirin be discontinued in the event of a lower gastrointestinal (GI) bleed?

Management of Baby Aspirin in Lower GI Bleeding

For patients taking baby aspirin for secondary cardiovascular prevention, aspirin should NOT be discontinued during a lower GI bleed as the mortality benefit of continuing aspirin outweighs the increased risk of rebleeding. 1

Decision Algorithm Based on Indication

Secondary Prevention (established cardiovascular disease)

• Continue aspirin without interruption during and after lower GI bleeding
• Evidence shows 10x lower all-cause mortality when aspirin is continued (1.3% vs 12.9%) despite a numerically higher rebleeding rate 1
• A retrospective study demonstrated nearly 7-fold increased risk of death or acute cardiovascular events in patients who discontinued aspirin therapy 1

Primary Prevention

• Permanently discontinue aspirin if it was only being used for primary prevention 1
• The cardiovascular benefit does not outweigh bleeding risk in this population

Management During Acute Bleeding

1. Resuscitate the patient and achieve hemostasis through appropriate interventions
2. Continue aspirin throughout the bleeding episode if used for secondary prevention
3. Coordinate with cardiology for patients with recent coronary stents or high thrombotic risk
4. Add a proton pump inhibitor to reduce risk of recurrent bleeding

Special Considerations for Dual Antiplatelet Therapy (DAPT)

If patient is on DAPT (aspirin plus P2Y12 inhibitor):

• Continue aspirin without interruption
• Temporarily withhold the P2Y12 inhibitor (clopidogrel, ticagrelor, prasugrel) 1
• Restart P2Y12 inhibitor within 5 days after hemostasis is achieved 1
• Never discontinue both antiplatelet agents simultaneously due to high risk of stent thrombosis 1

Timing of Restarting Therapy

• For patients where aspirin was temporarily held:
  • Resume aspirin immediately after hemostasis is achieved 1
  • For P2Y12 inhibitors: restart within 5 days maximum 1
  • For patients with drug-eluting stents: restart P2Y12 inhibitors as early as possible within the 5-day window 1

Risk Stratification

The decision to continue aspirin should consider:

1. Thrombotic risk: Higher in patients with recent coronary stents, recent stroke, or mechanical heart valves
2. Bleeding severity: Life-threatening hemorrhage may require temporary discontinuation with rapid reinitiation
3. Bleeding source: If bleeding source has been identified and treated, earlier reinitiation is safer

Common Pitfalls to Avoid

• Discontinuing aspirin in secondary prevention: This increases mortality significantly 2, 3
• Continuing both agents in DAPT: If temporary discontinuation is needed, stop only the P2Y12 inhibitor
• Delaying restart beyond 5-7 days: Increases thrombotic risk unnecessarily 4
• Failing to add PPI therapy: Concomitant PPI therapy significantly reduces rebleeding risk 5

Long-term Outcomes

Studies show that while continuing aspirin after GI bleeding increases rebleeding risk (18.9% vs 6.9%), it significantly reduces serious cardiovascular events (22.8% vs 36.5%) and mortality (8.2% vs 26.7%) over 5 years 2, making continuation the preferred strategy for patients on aspirin for secondary prevention.