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

Aspirin Therapy in a 76-Year-Old Male with Prior GI Bleeding and Coronary Artery Disease

This patient should start low-dose aspirin (75-81 mg daily) for secondary prevention of cardiovascular events, but ONLY with mandatory proton pump inhibitor (PPI) co-therapy (omeprazole or esomeprazole 20-40 mg daily) and after H. pylori testing with eradication if positive. 1

Cardiovascular Benefit Justification

• In patients with established coronary artery disease, aspirin reduces major vascular events by approximately 20 per 1,000 patients per year, making the cardiovascular benefit substantial for secondary prevention 1
• The ACC/AHA guidelines strongly recommend aspirin for secondary prevention in patients with established CAD, as this population has demonstrated clear mortality and morbidity reduction 2
• For secondary prevention (which this patient qualifies for with native coronary artery disease), aspirin prevents strokes, deaths, and myocardial infarctions—a far more favorable benefit profile than primary prevention 2

Bleeding Risk Assessment and Mitigation

Quantifying the Risk

• Low-dose aspirin (75-81 mg daily) doubles the risk of upper GI bleeding compared to non-users, with an absolute risk of approximately 1 per 100 patient-years in real-world practice 2, 1
• This patient has TWO major risk factors: age >75 years and history of GI bleeding, placing him at substantially elevated risk for recurrent hemorrhage 1, 3
• Major GI bleeding carries a 5-10% mortality rate when hospitalization is required 1

Mandatory Risk Mitigation Strategy

The following interventions are NOT optional—they are requirements for safe aspirin use in this high-risk patient:

• PPI co-therapy is essential: Omeprazole or esomeprazole 20-40 mg daily reduces recurrent aspirin-induced GI bleeding more effectively than any other strategy 1, 4, 5
• H. pylori testing and eradication if positive is required to further reduce bleeding risk 1, 5
• Use the lowest effective aspirin dose: 75-81 mg daily, as higher doses provide no additional cardiovascular benefit but significantly increase bleeding risk 2, 1

Monitoring Requirements

• Regular hemoglobin/hematocrit monitoring every 3-6 months 1
• Immediate evaluation for any signs of bleeding (melena, hematemesis, unexplained anemia, fatigue) 1
• Ensure the patient understands warning signs and has clear instructions to seek immediate care if bleeding occurs 1

Absolute Contraindications to Verify Are Absent

Do NOT start aspirin if any of the following are present:

• Active or recent (within 2-3 months) GI bleeding 1
• Concurrent anticoagulation therapy (warfarin, DOACs) 1
• Severe anemia or coagulopathy 1
• Inability to reliably take daily PPI 1
• Age 60 or older with history of stomach ulcers or bleeding problems AND taking blood thinners or steroids 6

Critical Pitfalls to Avoid

• Never use enteric-coated aspirin as a substitute for PPI therapy—the protective effect of gastro-resistant coating is debatable and insufficient for high-risk patients 3
• Avoid concurrent NSAIDs absolutely, as this dramatically increases bleeding risk 2, 3, 5
• Do not use aspirin doses >100 mg—there is no cardiovascular benefit and bleeding risk increases substantially 2
• Never assume the patient's prior GI bleeding was "too long ago to matter"—history of GI bleeding remains a persistent risk factor 3, 5

Alternative Consideration

If the patient cannot reliably take daily PPI, has had GI bleeding within the past 2-3 months, or has other absolute contraindications, optimize alternative cardiovascular risk reduction strategies instead: maximize statin therapy, ACE inhibitor or ARB, and beta-blocker if post-MI 1