A 62-year-old man on aspirin 75 mg and clopidogrel after recent coronary stent placement develops haematemesis. Upper GI endoscopy shows a 1.5 cm duodenal ulcer with a visible vessel (Forrest Ia). What is the MOST appropriate management of dual antiplatelet therapy in this high-risk upper GI bleed?

• A Stop both antiplatelet agents permanently
• B Stop clopidogrel only; continue aspirin throughout ✓
• C Stop both agents during hospitalization; restart aspirin alone after 3–5 days
• D Continue both agents and add a proton pump inhibitor

Explanation

In patients with acute coronary syndrome or recent stent who develop high-risk upper GI bleeding, aspirin should be continued (or restarted within 1–5 days) while the P2Y12 inhibitor (clopidogrel) may be temporarily withheld, as the risk of stent thrombosis from stopping both antiplatelet agents generally outweighs the marginal rebleeding risk from aspirin alone after adequate endoscopic haemostasis. This strategy is supported by ACCF/ACG/AHA consensus documents. High-dose PPI infusion reduces rebleed risk. Stopping both agents risks catastrophic stent thrombosis.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.