When to discontinue aspirin (acetylsalicylic acid) in elderly patients?

Discontinuation of Aspirin in the Elderly

For elderly patients ≥60 years without established cardiovascular disease, aspirin should be discontinued for primary prevention due to bleeding risks that outweigh minimal cardiovascular benefits, while those with established atherosclerotic cardiovascular disease should generally continue aspirin indefinitely unless specific high-risk bleeding scenarios arise. 1, 2

Primary Prevention: Discontinue Aspirin

For adults ≥60 years taking aspirin for primary prevention (no history of MI, stroke, or coronary revascularization), aspirin should be stopped. 2

• The US Preventive Services Task Force recommends against initiating or continuing low-dose aspirin for primary prevention in adults ≥60 years, as the net benefit is absent due to increased bleeding risk that equals or exceeds any cardiovascular benefit 2
• For adults aged 70+ years with diabetes but without established atherosclerotic cardiovascular disease, aspirin for primary prevention has greater bleeding risk than cardiovascular benefit 1
• A target trial emulation study of 6,103 CVD-free older adults (≥70 years) demonstrated that aspirin cessation versus continuation showed no increased risk of cardiovascular events, MACE, or mortality over 48 months, but significantly reduced major bleeding risk (HR 0.63, p<0.05) 3
• The bleeding risk in real-world settings may be as high as 5 per 1,000 per year, with the number of bleeding episodes induced similar to ASCVD events prevented in this age group 1

Secondary Prevention: Continue Aspirin (With Important Exceptions)

For elderly patients with established atherosclerotic cardiovascular disease (prior MI, stroke, or coronary revascularization), aspirin 75-100 mg daily should be continued indefinitely, as mortality benefits substantially outweigh bleeding risks. 1, 4, 5

Key Indications for Continuation:

• Prior myocardial infarction 1
• Prior ischemic stroke 1
• History of coronary revascularization (PCI or CABG) 1, 5
• Established chronic coronary disease 1, 5

Critical Exception: Atrial Fibrillation on Anticoagulation

In elderly patients with atrial fibrillation requiring oral anticoagulation who undergo PCI, aspirin should be discontinued after 1-4 weeks of triple therapy, maintaining only P2Y12 inhibitor plus anticoagulant (dual therapy). 1

• The 2023 ACC/AHA guidelines and 2025 ACS guidelines establish this as a Class I recommendation to reduce bleeding risk 1
• Discontinuation earlier than 1 week is acceptable when the patient is taking a P2Y12 inhibitor and has resumed therapeutic anticoagulation 1
• Triple therapy up to 4 weeks is reasonable only for patients with high thrombotic and low bleeding risk, but dual antithrombotic therapy (P2Y12 plus DOAC) should be the default 1
• The AUGUSTUS and ENTRUST-AF-PCI trials demonstrated lower bleeding rates with dual therapy versus triple therapy, with similar rates of death, MI, and stent thrombosis 1

Optimal Aspirin Dosing When Continued

When aspirin is indicated for secondary prevention in the elderly, use 75-100 mg daily—the lowest effective dose. 4, 5

• Daily doses of 75-100 mg are as effective as higher doses for long-term secondary prevention while minimizing gastrointestinal toxicity 4, 5
• Aspirin doses above 100 mg provide no additional cardiovascular benefit but increase bleeding risk 4, 5

Mandatory Gastroprotection

All elderly patients continuing aspirin should receive concurrent proton pump inhibitor (PPI) therapy to reduce gastrointestinal bleeding risk. 4, 5

• PPIs should be prescribed for all patients on antiplatelet therapy for as long as treatment continues (Class I recommendation from European Society of Cardiology) 4, 5
• This is particularly critical for patients with history of GI bleeding, concurrent NSAID use, or other bleeding risk factors 4

Risk Stratification for Bleeding

High-Risk Scenarios Requiring Aspirin Discontinuation:

• Severe thrombocytopenia (<50,000/μL) 4
• Active or life-threatening bleeding 4
• Recent intracranial hemorrhage 1
• Active peptic ulcer disease 1

Moderate-Risk Scenarios Requiring Individualized Assessment:

• Moderate thrombocytopenia (50,000-100,000/μL)—consult cardiology before discontinuing in high thrombotic risk patients 4
• History of gastrointestinal bleeding—continue aspirin with PPI if cardiovascular indication is strong 4
• Age >75 years with multiple bleeding risk factors (renal failure, anemia, concurrent anticoagulation) 1, 4

Risks of Inappropriate Discontinuation

Abrupt discontinuation of aspirin in patients with established cardiovascular disease carries substantial thrombotic risk. 6

• A Swedish nationwide cohort study of 601,527 aspirin users demonstrated that discontinuation increased cardiovascular event risk by 37% (HR 1.37,95% CI 1.34-1.41), corresponding to one additional cardiovascular event per year in every 74 patients who discontinue 6
• The risk increases shortly after discontinuation and does not diminish over time 6
• In patients with recent acute coronary syndrome and established CVD who had peptic ulcer bleeding, resuming aspirin immediately after endoscopic hemostasis reduced all-cause mortality by 10-fold (1.3% vs 12.9%) despite numerically higher rebleeding rates 4

Special Considerations for Post-PCI Patients

Elderly patients who have undergone PCI should continue dual antiplatelet therapy (aspirin plus P2Y12 inhibitor) for 12 months after acute coronary syndrome, regardless of stent type. 5

• For stable coronary disease, DAPT should continue for minimum 6 months after drug-eluting stent implantation 5
• After completing the recommended DAPT duration, discontinue the P2Y12 inhibitor and continue aspirin monotherapy indefinitely 5
• Patients with coronary stents who discontinue aspirin have nearly 7-fold increased risk for death or acute cardiovascular events 4

Common Pitfalls to Avoid

• Do not reflexively discontinue aspirin based solely on advanced age (≥75 years) in patients with established cardiovascular disease—the indication matters more than age alone 4
• Do not combine omeprazole or esomeprazole with clopidogrel if dual antiplatelet therapy is needed, as these PPIs inhibit CYP2C19 and reduce clopidogrel's efficacy 4
• Do not use platelet transfusions to "cover" aspirin use in thrombocytopenic patients, as this strategy increases mortality without reducing bleeding 4
• Do not restart aspirin at doses >100 mg after bleeding events—this increases bleeding risk without improving cardiovascular outcomes 4

Practical Implementation

A pharmacist-led deprescribing intervention can effectively discontinue inappropriate aspirin use in elderly patients. 7

• In a safety-net health system study of 131 eligible patients ≥70 years on aspirin without documented ASCVD, 60% successfully discontinued aspirin after pharmacist intervention, with median time spent of approximately 8 minutes per patient 7
• Active pharmacist outreach was more effective than written recommendations to providers 7