Should aspirin (Ecosprin) be stopped in a patient with a history of cerebrovascular accident (CVA) presenting with bleeding per urethra?

Management of Aspirin in CVA Patient with Urethral Bleeding

Aspirin should be temporarily discontinued for 5 days in a CVA patient presenting with bleeding per urethra, while ensuring close cardiology consultation and early resumption once hemostasis is achieved. 1, 2

Immediate Management Approach

Discontinue aspirin temporarily but plan for early resumption - this is the critical balance required in this clinical scenario. 2

• For patients with moderate to severe hematuria on aspirin monotherapy, temporary discontinuation is recommended while bleeding is controlled 2
• The urological guidelines specifically recommend that for CVA patients on aspirin for secondary stroke prevention, aspirin should be continued through most procedures, but urethral bleeding represents active hemorrhage requiring intervention 1
• Aspirin should be resumed as soon as adequate hemostasis is achieved, ideally within 5 days 2, 3

Risk Stratification Considerations

The decision hinges on weighing thrombotic versus hemorrhagic risks:

Thrombotic Risk (Very High in CVA Patients):

• Aspirin interruption in patients on secondary prevention is associated with a three-fold increased risk of cardiovascular or cerebrovascular events 1
• 70% of these thrombotic events occur within 7-10 days after aspirin interruption 1
• A thrombotic stroke may result in lifelong disability, which is often worse than the consequences of urethral bleeding 1

Hemorrhagic Risk:

• Urethral bleeding can typically be controlled with urological interventions 1
• Aspirin increases bleeding risk by approximately 1.5-fold, but does not increase the severity of bleeding complications 1
• Major bleeding complications requiring transfusion or intervention remain uncommon (1.9%) even with continued aspirin 1

Specific Management Algorithm

Step 1: Immediate Actions

• Stop aspirin temporarily 2
• Initiate urological evaluation and hemostatic measures 1
• Do NOT use prophylactic heparin or LMWH as "bridging" - this does not reduce stroke risk and increases bleeding 1

Step 2: Determine Timing of CVA

• If CVA was recent (< 3 months): Neurological consultation is mandatory to evaluate competing risks 1
• If CVA was remote (> 3 months): Standard 5-day discontinuation is reasonable 2

Step 3: Resume Aspirin Early

• Resume aspirin within 5 days after bleeding control is achieved 2, 3
• A recent study in peptic ulcer bleeding showed that patients who continued aspirin had small increases in rebleeding but lower overall and cardiovascular 30-day mortality compared to those who stopped 3

Critical Pitfalls to Avoid

Do NOT discontinue aspirin indefinitely - this is the most dangerous error:

• The cardiovascular/cerebrovascular risk from prolonged aspirin discontinuation far exceeds the bleeding risk in most cases 1
• Hemorrhagic complications from urological procedures are rarely fatal, whereas recurrent stroke can be catastrophic 1

Do NOT use bridging anticoagulation:

• Low-molecular-weight heparins do not reduce stroke risk and significantly increase bleeding complications 1
• There is insufficient evidence supporting heparin bridging to reduce thromboembolic events 4

Do NOT treat this as primary prevention:

• If aspirin was being used for primary prevention (no prior CVA), it would be reasonable to stop aspirin and re-evaluate the indication 3
• However, this patient has established CVA, making this secondary prevention with much higher stakes 1

Special Considerations

If urological procedure is required:

• Most urological procedures can be performed safely with aspirin monotherapy continued 1
• For cystoscopy or other endoscopic procedures, aspirin continuation is generally acceptable with minor bleeding risk 1
• Urologists should be counseled that the thrombotic risk of aspirin discontinuation in recent CVA patients outweighs procedural bleeding risk 1

Monitoring after resumption:

• Close follow-up for recurrent bleeding is essential 2
• If hematuria recurs on aspirin, consider switching to clopidogrel as an alternative antiplatelet agent 2
• Ensure adequate blood pressure control, as hypertension may contribute to urological bleeding 1