Aspirin Management After Hematemesis from Gastric Telangiectasia in CVA Patient
You should restart aspirin as soon as hemostasis is achieved, ideally within 24-48 hours, because the mortality risk from recurrent stroke far exceeds the risk of rebleeding in secondary prevention patients. 1
Critical Evidence Supporting Aspirin Resumption
The thrombotic risk of withholding aspirin dramatically outweighs bleeding concerns in stroke patients:
Patients who discontinued aspirin after gastrointestinal bleeding had mortality rates 10 times higher (12.9% vs 1.3%) compared to those who continued aspirin, despite slightly higher rebleeding rates 1
Stopping aspirin increases the risk of death or acute cardiovascular events nearly 7-fold (HR 6.9; 95% CI 1.4-34.8) 1
For secondary prevention (which includes your CVA patient), aspirin should not be routinely stopped, and if held temporarily, must be restarted urgently once hemostasis is achieved 1, 2
Defining Hemostasis Before Restarting
Hemostasis is achieved when: 2
- Hemoglobin remains stable over 12-24 hours
- No ongoing transfusion requirements exist
- Imaging (if obtained) shows stable or resolving bleeding source
Timing of Aspirin Resumption
Restart aspirin within 24-48 hours after achieving hemostasis 1, 2
Most rebleeding occurs within the first 5 days, but the thrombotic risk begins immediately upon aspirin discontinuation 1
The American Heart Association and American College of Cardiology both emphasize that aspirin should not be withheld indefinitely in secondary prevention patients 2
Important Caveats for Your Specific Case
Gastric telangiectasia presents unique considerations:
Unlike peptic ulcer disease where endoscopic hemostasis can be definitively achieved, telangiectasias are chronic vascular malformations that may have ongoing bleeding potential 3, 4
Aspirin's dual mechanism increases bleeding risk: it causes mucosal injury AND impairs hemostasis through thromboxane inhibition—both effects are necessary for significant bleeding 3, 4
Consider these protective strategies when restarting: 5
- Add proton pump inhibitor therapy (though this primarily protects against acid-related lesions, not telangiectasias)
- Use plain (non-enteric coated) aspirin to ensure consistent absorption and platelet inhibition 6
- Consider the lowest effective dose (81-100 mg daily) rather than higher doses 7
What NOT to Do
Do not permanently discontinue aspirin in this secondary prevention patient 1
- This recommendation applies only to primary prevention patients, where bleeding risk exceeds cardiovascular benefit 1, 2
Do not give platelet transfusions 1
- Routine platelet transfusion in antiplatelet-related GI bleeding does not reduce rebleeding but is associated with higher mortality 1
Risk-Benefit Analysis
The evidence strongly favors resumption:
Cohort studies consistently show that patients who continued aspirin after major hemorrhage had significantly more cardiovascular events and deaths compared to those who restarted it, despite having fewer rebleeding events 1, 2
The UK-TIA trial showed dose-dependent bleeding risk (odds ratio 3.3 for 300mg aspirin), but this must be weighed against stroke prevention benefits in your patient with established cerebrovascular disease 7
Aspirin-related GI bleeding, while serious, rarely causes death in the age groups typically affected, unlike recurrent stroke which carries high mortality and morbidity 4