Should a 76-year-old male with a history of gastrointestinal (GI) bleeding and coronary artery disease (CAD) with angina pectoris start taking baby aspirin (acetylsalicylic acid)?

Should This 76-Year-Old Male with Recent GI Bleeding and CAD with Angina Start Baby Aspirin?

Yes, aspirin should be started at 75-81 mg daily with mandatory proton pump inhibitor (PPI) co-therapy once hemodynamic stability is achieved and active bleeding has resolved, as the mortality benefit of aspirin for secondary prevention in established coronary artery disease substantially outweighs the bleeding risk when appropriate gastroprotection is provided. 1, 2

Rationale: Cardiovascular Benefit vs. Bleeding Risk in Secondary Prevention

The decision hinges on understanding that this patient has established coronary artery disease with angina—this is secondary prevention, not primary prevention, which fundamentally changes the risk-benefit calculation:

• In secondary prevention (like this patient), aspirin prevents approximately 20 major vascular events per 1,000 patients per year, with a number needed to treat of only 106 to prevent one recurrent cardiovascular event 3, 1
• In contrast, primary prevention would cause 5-7 GI bleeds for each MI prevented, which is why the FDA declined to approve aspirin for primary prevention 3
• For this patient with established CAD and angina, more than two recurrent strokes or MIs can be prevented at the cost of one GI bleed 3
• Discontinuing aspirin after GI bleeding is associated with double the one-year all-cause mortality (hazard ratio 2.16) without increasing re-bleeding risk 4

Mandatory Gastroprotection Strategy

PPI co-therapy is non-negotiable in this high-risk patient (age 76 + recent GI bleeding history):

• Omeprazole or esomeprazole 20-40 mg daily reduces recurrent aspirin-induced GI bleeding more effectively than any other strategy 1
• PPIs reduce upper GI bleeding to a greater degree than H2 receptor antagonists 3
• H. pylori testing and eradication if positive is recommended to further reduce bleeding risk 1, 5
• PPI therapy should continue indefinitely as long as aspirin is required 2

Optimal Aspirin Dosing

Use 75-81 mg daily—the lowest effective dose:

• Daily doses of 75-100 mg are as effective as higher doses for secondary prevention while minimizing GI toxicity 3, 2, 6
• Even at 75 mg/day, the risk of upper GI bleeding is doubled compared to non-users, but this is the safest effective dose 3
• Aspirin doses above 100 mg provide no additional cardiovascular benefit but significantly increase bleeding risk 2

Timing of Aspirin Initiation

Aspirin should be restarted as soon as there is no concern over active bleeding, typically within days to weeks after the acute GI bleeding event is resolved and hemodynamic stability is achieved 2:

• The key is ensuring the bleeding source has been identified and treated (if possible)
• Hemoglobin should be stable without ongoing transfusion requirements
• Do not delay unnecessarily—aspirin interruption is associated with a three-fold increased risk of cardiovascular events, with 70% occurring within 7-10 days 2

Risk Factors That Increase Bleeding Risk (But Don't Contraindicate Aspirin)

This patient has multiple risk factors that elevate his GI bleeding risk, but with PPI co-therapy, aspirin remains indicated 3, 1:

• Age >75 years (he is 76)
• History of prior GI bleeding (recent)
• The FDA label specifically warns that "the chance is higher if you are age 60 or older" and "have had stomach ulcers or bleeding problems" 7

Absolute Contraindications to Consider

Aspirin should NOT be started if any of the following apply 1:

• Active or very recent GI bleeding (within 2-3 weeks, depending on severity and source control)
• Concurrent anticoagulation therapy (would require careful risk-benefit discussion)
• Severe anemia or coagulopathy
• Inability to reliably take daily PPI

Monitoring Strategy

Once aspirin is initiated with PPI:

• Regular hemoglobin/hematocrit monitoring every 3-6 months 1
• Immediate evaluation for any signs of bleeding (melena, hematemesis, unexplained anemia) 1
• Continue PPI therapy indefinitely 2
• Avoid NSAIDs, which would dramatically increase bleeding risk 3, 7

Common Pitfalls to Avoid

• Do not use aspirin doses >100 mg—this increases bleeding risk without improving cardiovascular outcomes 2
• Do not delay aspirin restart excessively after GI bleeding has resolved—this increases cardiovascular mortality 4
• Do not omit PPI co-therapy in this high-risk patient—it is essential, not optional 3, 1
• Do not combine omeprazole/esomeprazole with clopidogrel if dual antiplatelet therapy is ever needed, as these PPIs reduce clopidogrel's effectiveness 2

Alternative Only If Aspirin Absolutely Cannot Be Used

If aspirin cannot be restarted due to recurrent life-threatening bleeding despite PPI therapy, clopidogrel 75 mg daily is a reasonable alternative, though it also carries GI bleeding risk 2:

• This is a last resort, not a first-line alternative
• Clopidogrel alone is less well-studied than aspirin for stable CAD with angina