Should aspirin (acetylsalicylic acid) 81mg be held in an 86-year-old male with coronary artery disease (CAD) and history of coronary artery bypass grafting (CABG) prior to an esophagogastroduodenoscopy (EGD) for suspected gastritis or mild gastrointestinal bleed, and if so, for how long?

Management of Aspirin Therapy Before EGD in an Elderly Patient with CAD and Suspected GI Bleed

Aspirin 81mg should be temporarily held for 3-5 days prior to the EGD procedure in this 86-year-old male with suspected gastritis or mild gastrointestinal bleeding, despite his history of CAD and remote CABG. 1, 2

Risk Assessment and Decision Algorithm

Bleeding Risk vs. Cardiovascular Risk

• The patient presents with epigastric pain concerning for gastritis or mild GI bleed, which represents an active bleeding risk that outweighs the short-term cardiovascular risk of temporarily discontinuing aspirin 2, 3
• While aspirin is recommended indefinitely after coronary interventions, temporary interruption is appropriate when active bleeding is suspected 1, 3
• The remote timing of CABG (2019) places this patient at lower risk for acute cardiovascular events during brief aspirin interruption compared to patients with recent interventions 4, 1

Timing of Aspirin Discontinuation

• For patients undergoing elective procedures with bleeding risk, aspirin should be discontinued for at least 3-5 days before the procedure 4
• This timeframe allows for adequate reduction in bleeding risk while minimizing the period of cardiovascular vulnerability 4, 3
• For patients with suspected active GI bleeding, immediate discontinuation is appropriate until source control is achieved 2, 3

Resumption of Aspirin Therapy

• After successful endoscopic therapy and source control, aspirin should be reintroduced within 5 days of the last dose to minimize cardiovascular risk 3
• Early reintroduction (within 24-72 hours after EGD) is appropriate if no high-risk bleeding stigmata are found and hemostasis is achieved 2, 3
• If significant bleeding is identified, aspirin may need to be held longer, with consideration for PPI co-therapy upon resumption 2

Special Considerations for This Patient

Age-Related Factors

• At 86 years of age, this patient has increased risk for GI bleeding complications with aspirin therapy 5
• The FDA warns that patients age 60 or older have a higher chance of stomach bleeding with aspirin use 5
• However, his history of CAD and CABG indicates a continued benefit from aspirin therapy once bleeding is controlled 1

Endoscopic Procedure Considerations

• EGD is considered a high-risk procedure for bleeding when performed in the setting of active or suspected GI bleeding 2
• Continuing aspirin during EGD could complicate visualization and therapeutic interventions 2, 3
• If urgent EGD is required and aspirin cannot be held for the full 3-5 days, the procedure should still proceed with awareness of potentially increased bleeding risk 3

Post-Procedure Management

• After EGD with successful source control, initiate PPI therapy (standard once-daily dosing such as omeprazole 20mg daily or pantoprazole 40mg daily) 2
• Resume aspirin at the 81mg dose (preferred over higher doses) once hemostasis is confirmed 4, 1
• Consider indefinite PPI co-therapy in this elderly patient with history of GI bleeding to reduce recurrent bleeding risk 2, 3

Common Pitfalls to Avoid

• Continuing aspirin despite active GI bleeding, which can worsen bleeding and complicate endoscopic visualization 2, 5
• Discontinuing aspirin for unnecessarily long periods (>7 days), which increases cardiovascular risk 4, 3
• Failing to resume aspirin therapy after successful bleeding source control, especially in patients with coronary stents or prior CABG 1, 3
• Using higher maintenance doses of aspirin (>81mg) upon resumption, which increases bleeding risk without additional cardiovascular benefit 4, 1