Management of Aspirin in Cases of Bleeding
In cases of significant bleeding, aspirin should be temporarily discontinued if used for primary prevention, but should be continued or restarted as soon as hemostasis is achieved if used for secondary prevention of cardiovascular events. 1, 2
Decision Framework Based on Indication
Primary Prevention
- Aspirin used for primary prevention of cardiovascular events should be permanently discontinued when bleeding occurs, as the bleeding risk outweighs the cardiovascular benefit 1, 2
- FDA warns that aspirin may cause severe stomach bleeding, especially in patients who are older, have had stomach ulcers, or take blood thinners 3
Secondary Prevention
- For patients on aspirin for secondary prevention (established cardiovascular disease):
- Temporarily withhold aspirin only during active serious or life-threatening bleeding 1, 2
- Restart aspirin as soon as hemostasis is achieved 1, 2
- Discontinuation of aspirin for secondary prevention is associated with a nearly sevenfold increase in risk for death or acute cardiovascular events 2
- All-cause mortality is 10 times lower in patients who resume aspirin immediately after endoscopic hemostasis compared to those who discontinue it 1, 2
Management Based on Bleeding Type
Gastrointestinal Bleeding
- For upper GI bleeding in patients on aspirin for secondary prevention, temporarily withhold aspirin only during active bleeding and restart as soon as hemostasis is achieved 1, 2
- For lower GI bleeding, aspirin for secondary prevention should not be routinely stopped, and if stopped, should be restarted as soon as hemostasis is achieved 1
Perioperative Bleeding
- In most surgeries, low-dose aspirin may result in increased frequency of procedural bleeding (relative risk 1.5) but not an increase in the severity of bleeding complications or perioperative mortality 1
- Aspirin should only be discontinued if the known bleeding risks are similar or more severe than the observed cardiovascular risks of aspirin withdrawal 1
- If aspirin must be discontinued preoperatively, it can be stopped 5 days before elective surgery (with operation on the sixth day), as platelet function tests normalize within 144 hours after stopping aspirin 4
Dual Antiplatelet Therapy Considerations
- For patients on dual antiplatelet therapy (DAPT), never withhold both antiplatelet agents simultaneously due to high risk of stent thrombosis 1, 2, 5
- In patients on DAPT with aspirin and clopidogrel who experience bleeding, continue aspirin and temporarily withhold clopidogrel 1, 2, 5
- P2Y12 receptor antagonist therapy should be reinstated within 5 days after hemostasis is achieved 1, 2, 5
Special Considerations
Bleeding Risk Assessment
- Patients with hemophilia or other bleeding disorders should avoid aspirin 6
- Patients taking anticoagulants have increased risk of bleeding with aspirin 3
- The risk of stopping antiplatelet therapy should be weighed against the benefit of reduction in bleeding complications 1
Intracranial and Major Surgery
- Aspirin discontinuation may be warranted for intracranial surgery and prostatectomy due to higher bleeding risks 1
- For urological procedures, recommendations vary by procedure type:
Common Pitfalls to Avoid
- Unnecessarily prolonged discontinuation of aspirin for secondary prevention increases thrombotic risk and mortality 2
- Simultaneous discontinuation of both antiplatelet agents in patients on DAPT can lead to stent thrombosis in as little as 7 days 1, 2
- Administering platelet transfusions for patients on antiplatelet therapy with GI bleeding has not been shown to reduce rebleeding and may be associated with higher mortality 1