In an elderly patient with a recent ischemic stroke who has an upper gastrointestinal bleed from gastric erosions, when should antiplatelet therapy be restarted and what regimen is recommended?

Antiplatelet Resumption After Upper GI Bleed in Elderly Stroke Patients

Resume aspirin immediately after endoscopic hemostasis is achieved, as the mortality benefit dramatically outweighs rebleeding risk, with all-cause mortality reduced 10-fold (1.3% vs 12.9%) compared to withholding aspirin. 1

Immediate Management During Active Bleeding

Continue aspirin without interruption during the acute bleeding episode in elderly stroke patients, as discontinuation increases cardiovascular mortality nearly 7-fold (HR 6.9). 1 The European Society of Gastrointestinal Endoscopy recommends very early endoscopy (within 12 hours) for patients with hemodynamic instability to achieve hemostasis and allow earlier antiplatelet resumption. 2, 3

Key steps during active bleeding:

• Maintain aspirin therapy throughout the bleeding episode 1, 3
• Initiate IV proton pump inhibitor immediately 2, 3
• Perform urgent upper GI endoscopy within 12 hours 2, 3
• Provide hemodynamic support with IV fluids and transfusion as needed 2

Timing of Antiplatelet Resumption

Resume aspirin 75-100 mg daily immediately after endoscopic hemostasis is documented, regardless of the 30-day rebleeding risk being numerically higher, because the mortality reduction is paramount. 1 This recommendation is based on landmark trial data showing that immediate aspirin resumption after endoscopic treatment of gastric erosions reduces death by 10-fold. 1

For patients on dual antiplatelet therapy prior to the bleed:

• Continue aspirin without interruption 1, 3
• Withhold clopidogrel temporarily during active bleeding 1, 3
• Resume clopidogrel within 5 days after achieving endoscopic hemostasis 1, 3
• Never withhold both agents simultaneously, as stent thrombosis can occur within 7 days when both drugs are stopped (versus 122 days with only clopidogrel withheld) 1, 3

Gastroprotection Strategy

Mandatory high-dose PPI co-therapy must be prescribed concurrently with aspirin resumption, as PPIs reduce upper GI bleeding risk by 68-87% in aspirin users. 3 This is non-negotiable given the patient's demonstrated bleeding risk from gastric erosions. 2, 3

The concern about PPI-clopidogrel interaction should not prevent PPI use in this high-risk bleeding scenario:

• PPIs are recommended for patients with prior GI bleeding history 2
• The bleeding risk reduction outweighs theoretical concerns about reduced clopidogrel efficacy 2
• Consider using pantoprazole if clopidogrel is required, though evidence for differential interaction is limited 2

Risk Stratification for This Patient

This elderly stroke patient has multiple high-risk features for GI bleeding that warrant aggressive gastroprotection:

• Advanced age (≥75 years increases bleeding risk) 3
• History of gastric erosions (documented bleeding source) 2
• Requirement for antiplatelet therapy (2-3 fold increased bleeding risk) 2

However, the thromboembolic risk from stroke recurrence is substantial:

• Recent ischemic stroke carries 3% annual risk of recurrent vascular events 2
• The absolute benefit of aspirin (preventing 20 major vascular events per 1,000 patients/year in secondary prevention) far exceeds the harm (causing 1-2 major GI bleeds per 1,000 patients/year) 2

Monitoring After Resumption

After restarting antiplatelet therapy:

• Check hemoglobin weekly for the first month 1
• Educate patient on signs of recurrent bleeding (melena, hematemesis, dizziness) 1
• Ensure PPI compliance is maintained long-term 2, 3
• Assess for Helicobacter pylori and treat if present, as this reduces rebleeding risk 2

Critical Pitfalls to Avoid

Do not unnecessarily prolong antiplatelet discontinuation beyond the time needed to achieve endoscopic hemostasis, as each day without aspirin increases thrombotic risk exponentially in stroke patients. 1, 3 The median time to stent thrombosis when both antiplatelets are withheld is only 7 days. 1

Do not restart dual antiplatelet therapy unless this patient has a recent coronary stent (within 6 months) or acute coronary syndrome, as dual therapy significantly increases major bleeding from 2.7% to 3.7% annually without corresponding benefit in non-cardioembolic stroke. 3, 4

Avoid NSAIDs completely, as concomitant NSAID use with aspirin dramatically increases GI bleeding risk. 2, 3

Special Consideration for Stroke Type

For non-cardioembolic ischemic stroke (most common in elderly patients):

• Aspirin monotherapy 75-100 mg daily is the standard of care 1, 5
• Dual antiplatelet therapy is not routinely recommended due to bleeding risk 2
• Anticoagulation is not indicated unless atrial fibrillation is present 5

If this patient has atrial fibrillation, anticoagulation should be resumed 4-7 weeks after the GI bleed has been definitively treated, as anticoagulation reduces thromboembolism by 55% and mortality by 38%. 1 However, aspirin should be continued in the interim period. 1