How long after an upper gastrointestinal (GI) bleed can aspirin (acetylsalicylic acid) be restarted?

Timing of Aspirin Resumption After Upper GI Bleeding

For patients on aspirin for secondary cardiovascular prevention, restart aspirin immediately after endoscopic hemostasis is achieved, as all-cause mortality is 10 times lower with immediate resumption compared to discontinuation, despite a numerically higher rebleeding rate. 1

Critical Distinction: Primary vs. Secondary Prevention

• Secondary prevention (established cardiovascular disease): Resume aspirin as soon as hemostasis is achieved—ideally within 1-3 days and no later than 7 days after bleeding cessation 2, 3
• Primary prevention (no established cardiovascular disease): Permanently discontinue aspirin, as bleeding risk outweighs cardiovascular benefit in this population 3, 4

Evidence Supporting Immediate Resumption

The timing decision is driven by compelling mortality data from a randomized controlled trial:

• Patients who resumed aspirin immediately after endoscopic hemostasis had 1.3% mortality at 8 weeks compared to 12.9% mortality in those who discontinued aspirin (10-fold reduction) 1
• The 30-day rebleeding rate was numerically twice as high with aspirin continuation, but this did not translate to increased mortality 1
• Discontinuing aspirin is associated with a sevenfold increase in risk of death or acute cardiovascular events (HR 6.9; 95% CI 1.4-34.8) compared to continuation 1, 5

Management Algorithm for Dual Antiplatelet Therapy (DAPT)

For patients on both aspirin and a P2Y12 inhibitor (clopidogrel, prasugrel, ticagrelor):

• Never discontinue both agents simultaneously—stent thrombosis can occur in as little as 7 days with both drugs withheld 1, 3
• Continue aspirin throughout the bleeding episode if possible 1
• Temporarily withhold the P2Y12 inhibitor during active bleeding 1
• Resume the P2Y12 inhibitor within 5 days maximum after endoscopic hemostasis to prevent stent thrombosis 1, 3
• For ticagrelor specifically, consider even earlier resumption within 2-3 days 3

Essential Protective Measures

• Initiate high-dose proton pump inhibitor (PPI) therapy in all patients restarting aspirin after GI bleeding 3, 6
• Use intravenous PPI with bolus followed by continuous infusion for 3 days after endoscopic hemostasis, then transition to twice-daily oral PPI 7
• The combination of aspirin plus PPI is superior to clopidogrel alone for preventing recurrent bleeding 6

Risk Stratification Considerations

The decision to restart aspirin depends on:

• Cardiovascular risk: Patients with recent acute coronary syndrome (within 6 months) or coronary stents have extremely high thrombotic risk 1
• Quality of hemostasis: Ensure adequate endoscopic hemostasis before resumption 1, 3
• Severity of bleeding: Temporarily withhold aspirin only during life-threatening or serious bleeding, then restart immediately after hemostasis 6

Common Pitfalls to Avoid

• Unnecessarily prolonged discontinuation of aspirin for secondary prevention dramatically increases thrombotic risk and mortality—this exceeds rebleeding risk 3, 6, 5
• Failing to differentiate primary from secondary prevention—only secondary prevention patients should resume aspirin 4, 6
• Simultaneous discontinuation of both antiplatelet agents in DAPT patients leads to rapid stent thrombosis 1, 3
• Delaying P2Y12 inhibitor resumption beyond 5 days in high-risk patients increases stent thrombosis risk 3, 4
• Omitting PPI co-therapy when restarting aspirin increases rebleeding risk 3, 6
• Administering platelet transfusions—this does not reduce rebleeding and may increase mortality 1

Consultation Recommendations

• Consult cardiology before making changes to antiplatelet therapy in patients with recent acute coronary syndrome, coronary stents (especially within 6 months), or very high thrombotic risk 1, 4, 6