Aspirin Management in CAD Patients After Endoscopically-Treated Bleeding Gastric Ulcer
Resume aspirin within 24-48 hours after successful endoscopic hemostasis, as continuing aspirin reduces all-cause mortality by 10-fold (1.3% vs 12.9%) despite a modest increase in rebleeding risk. 1
Immediate Post-Endoscopy Management
Continue aspirin immediately after endoscopic hemostasis while initiating high-dose intravenous PPI therapy (pantoprazole 80 mg bolus followed by 8 mg/hour infusion for 72 hours). 1 This approach is based on a landmark randomized trial showing that aspirin continuation after endoscopic therapy resulted in dramatically lower 8-week mortality (1.3% vs 12.9%) compared to aspirin discontinuation, despite a numerically higher 30-day rebleeding rate. 1
The cardiovascular risk of withholding aspirin is immediate and severe. Patients who discontinue aspirin after GI bleeding have a nearly 7-fold increased risk of death or acute cardiovascular events (HR 6.9; 95% CI 1.4-34.8) within the first 6 months. 1
Timing Algorithm for Aspirin Resumption
If aspirin was held during acute bleeding: Resume within 24-48 hours once hemostasis is confirmed (stable hemoglobin over 12-24 hours, no ongoing transfusion requirements, endoscopic evidence of controlled bleeding). 2, 3
If patient is on dual antiplatelet therapy (DAPT): Continue aspirin and temporarily withhold the P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel). Never withhold both agents simultaneously, as median time to stent thrombosis is only 7 days with both drugs withheld versus 122 days with only the P2Y12 inhibitor withheld. 1
Resume P2Y12 inhibitor: Restart within 5 days after endoscopic hemostasis, particularly in patients with drug-eluting stents. 1
Essential Gastroprotective Measures
Mandatory PPI co-therapy must be prescribed concurrently with aspirin resumption. 1, 4 Use high-dose PPI therapy:
- Intravenous: Pantoprazole 80 mg bolus, then 8 mg/hour for 72 hours 1
- Oral maintenance: Omeprazole 40 mg daily or equivalent PPI 4
Test and treat for H. pylori to reduce future bleeding risk in all patients resuming aspirin after ulcer bleeding. 4
PPIs reduce upper GI bleeding risk by 68-87% in aspirin users, making them essential for safe aspirin continuation. 1
Risk Stratification Considerations
High thrombotic risk patients (recent stent placement, acute coronary syndrome within 6 months, recent MI or stroke) require immediate aspirin resumption as cardiovascular mortality risk dramatically outweighs rebleeding concerns. 1, 2, 3
Consultation with cardiology is recommended before any antiplatelet discontinuation, particularly in patients with acute coronary syndrome within 6 months who have higher stent thrombosis risk than those with stable CAD. 1
Common Pitfalls to Avoid
Do not unnecessarily prolong aspirin discontinuation beyond 24-48 hours, as this significantly increases thrombotic risk and mortality, particularly in secondary prevention patients. 2, 3 The rebleeding risk is substantially lower than the cardiovascular mortality risk from aspirin withholding. 1
Do not use platelet transfusions in patients with GI bleeding on antiplatelet agents, as they do not reduce rebleeding and are associated with higher mortality. 1
Avoid omeprazole or esomeprazole if patient will be on clopidogrel, as these PPIs inhibit CYP2C19 and reduce clopidogrel's active metabolite exposure. Consider pantoprazole or lansoprazole instead. 1
Monitoring Requirements
- Check hemoglobin/hematocrit every 3-6 months during aspirin therapy 4
- Immediate evaluation for any signs of recurrent bleeding 4
- Ensure PPI compliance, as this is the primary protective measure against rebleeding 1
The evidence unequivocally supports aspirin continuation or early resumption in CAD patients after endoscopically-treated ulcer bleeding, as the mortality benefit far exceeds the modest increase in rebleeding risk when combined with appropriate PPI therapy. 1, 3