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Peptic ulcer bleeding in a patient taking aspirin for secondary cardiovascular prevention — ABIM Board MCQ

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HardAspirinPeptic ulcer bleeding in a patient taking aspirin for secondary cardiovascular preventionABIM Board

A 71-year-old man is hospitalized with melena and presyncope. Eight years ago, he had an anterior myocardial infarction treated with percutaneous coronary intervention; he has had no recurrent ischemic events and currently takes aspirin 81 mg daily as his only antiplatelet medication. He does not take anticoagulants or nonsteroidal anti-inflammatory drugs. Aspirin is withheld on arrival. After fluid resuscitation, upper endoscopy shows a duodenal ulcer with a nonbleeding visible vessel. Endoscopic clipping and thermal coagulation achieve hemostasis. Intravenous proton pump inhibitor therapy is initiated. Six hours later, he is hemodynamically stable with no recurrent melena or decrease in hemoglobin. Which of the following is the most appropriate antiplatelet-management strategy?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: B — Restart aspirin 81 mg today and continue proton pump inhibitor therapy

Explanation lettering: E = shown as A · A = shown as B · D = shown as C · B = shown as D · C = shown as E

This patient takes aspirin for secondary cardiovascular prevention because he has established coronary artery disease and a prior myocardial infarction. In patients with acute gastrointestinal bleeding who require cardiac aspirin for secondary prevention, aspirin generally should not be withheld. If it has been interrupted, it should be resumed on the day endoscopic hemostasis is confirmed. Therefore, aspirin 81 mg should be restarted today while proton pump inhibitor therapy is continued. A short delay until 72 hours (B) may seem attractive because early ulcer rebleeding commonly occurs during this interval, but successful endoscopic hemostasis is the recommended trigger for aspirin resumption. Randomized evidence indicates that immediate continuation can modestly increase recurrent bleeding while reducing mortality. Substitution with clopidogrel (C) is not required merely because aspirin-associated ulcer bleeding occurred; aspirin with gastroprotection remains appropriate when aspirin is indicated. Permanent discontinuation (D) would expose this patient to avoidable recurrent cardiovascular risk and would be more defensible if aspirin had been used only for primary prevention. Waiting for documented ulcer healing (E) creates a prolonged period without secondary-prevention antiplatelet therapy. The key distinction is that control of the bleeding source permits prompt aspirin resumption despite the ulcer's initially high-risk endoscopic stigma.

Reference: American College of Gastroenterology-Canadian Association of Gastroenterology Clinical Practice Guideline: Management of Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period (2022) — https://pubmed.ncbi.nlm.nih.gov/35297395/ How to Manage Anticoagulants and Antiplatelets During Endoscopic Procedures (2022) — https://www.asge.org/home/resources/publications/journal-scan/issue/how-to-manage-anticoagulants-and-antiplatelets-during-endoscopic-procedures Continuation of Low-Dose Aspirin Therapy in Peptic Ulcer Bleeding: A Randomized Trial (2010) — https://pubmed.ncbi.nlm.nih.gov/19949136/