Management of Aspirin in Patients Presenting with Haemoptysis
If aspirin is being used for secondary cardiovascular prevention, continue it without interruption during haemoptysis evaluation and treatment; if aspirin is for primary prevention only, permanently discontinue it. 1, 2
Risk Stratification by Indication
Secondary Prevention (Continue Aspirin)
Aspirin for secondary cardiovascular prevention should NOT be stopped during haemoptysis. Discontinuing aspirin in patients with established cardiovascular disease increases all-cause mortality approximately 10-fold (from 1.3% to 12.9%) and increases the risk of death or acute cardiovascular events nearly 7-fold (HR 6.9). 1, 2
The thrombotic risk of stopping aspirin far exceeds the bleeding risk in secondary prevention patients. Most major adverse cardiac events occur within 7-10 days of aspirin cessation, with a threefold increased risk of major adverse cardiac events overall. 1, 2
Initiate high-dose proton pump inhibitor (PPI) therapy immediately when continuing aspirin during haemoptysis. This reduces the risk of further bleeding complications. 2
Primary Prevention (Discontinue Aspirin)
- Permanently discontinue aspirin in patients using it for primary cardiovascular prophylaxis who develop haemoptysis. The bleeding risk outweighs the modest cardiovascular benefit in this population. 1
Management of Dual Antiplatelet Therapy (DAPT)
Patients with Coronary Stents
In patients on DAPT (aspirin plus P2Y12 inhibitor), continue aspirin and temporarily withhold only the P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor) if bleeding is life-threatening. 1, 2
Never discontinue both antiplatelet agents simultaneously. Stopping both drugs accelerates stent thrombosis dramatically—median time to thrombosis is only 7 days when both are stopped versus 122 days when only the P2Y12 inhibitor is held. 1, 2
Restart the P2Y12 inhibitor within 5 days maximum after achieving haemostasis. Beyond this window, the risk of stent thrombosis rises sharply. 1, 2
Mandatory cardiology consultation is required for patients with acute coronary syndrome or stent placement within the preceding 6 months. These patients have exceptionally high thrombotic risk. 1, 2
Haemoptysis-Specific Considerations
Immediate Management Priorities
Focus on identifying and treating the source of haemoptysis while maintaining aspirin in secondary prevention patients. The most common causes are pulmonary tuberculosis and post-tuberculous bronchiectasis. 3
Bronchial artery embolization is significantly more effective than medical treatment alone for immediate cessation of life-threatening haemoptysis. 3, 4
Mortality from haemoptysis in antiplatelet users is primarily driven by thrombotic complications from drug discontinuation, not exsanguination. 1, 2
Critical Pitfalls to Avoid
Do NOT administer platelet transfusions to patients on aspirin who present with haemoptysis. Platelet transfusion does not reduce rebleeding rates and is associated with higher mortality. 1, 2
Do NOT unnecessarily delay aspirin resumption if it was temporarily held. Each day of delay increases thrombotic risk exponentially in secondary prevention patients. 2
Aspirin irreversibly inhibits platelet function for 5-7 days, so even brief interruptions carry significant thrombotic risk in high-risk cardiovascular patients. 1
Practical Algorithm
For secondary prevention patients:
- Continue aspirin throughout haemoptysis evaluation 1, 2
- Add high-dose PPI immediately 2
- Proceed with bronchoscopy and bronchial artery embolization as indicated 3, 4
- If on DAPT, hold only P2Y12 inhibitor and restart within 5 days 1, 2
For primary prevention patients:
- Permanently discontinue aspirin 1
- Proceed with standard haemoptysis management 3, 5
- Reassess cardiovascular risk after bleeding resolves
For life-threatening massive haemoptysis in secondary prevention: