Higher Cardiometabolic Burden Doubles GI-Bleeding Risk in Long-Term Aspirin Users — What Clinicians and Patients Should Know

Article

Lead

A new analysis of UK Biobank data shows that people taking long-term aspirin for ischaemic cardiovascular disease who carry multiple cardiometabolic risk factors — such as diabetes, hypertension, obesity and dyslipidaemia — have substantially higher rates of first gastrointestinal (GI) bleeding. The study found a clear dose–response relationship: bleeding rates rose progressively with each additional cardiometabolic condition. BioMed Central

Why this matters

Aspirin remains a mainstay of secondary prevention for atherosclerotic cardiovascular disease (ASCVD), lowering risks of recurrent heart attack and stroke. But its antiplatelet action also increases the likelihood of bleeding, particularly in the gastrointestinal tract. Balancing aspirin’s cardiovascular benefit against bleeding harm requires individualized assessment — and this study supplies real-world data that sharpen that trade-off. AHA Journals

Study snapshot

Researchers analyzed 12,781 UK Biobank participants with prior ischaemic cardiovascular disease who were prescribed aspirin and followed them for a mean of 13.4 years to track first GI-bleeding events. Participants were scored for four cardiometabolic risk factors (obesity, diabetes, dyslipidaemia and hypertension). Incidence of GI bleeding rose from roughly 4.5 to 9.6 cases per 1,000 person-years between people with no risk factors and those with all four; adjusted hazard ratios climbed from ~1.09 (one risk factor) to 1.95 (four risk factors), with a highly significant trend (P-trend < 0.001). Diabetes and hypertension showed particularly strong independent associations with bleeding. BioMed Central

Clinical implications

• Individualised risk–benefit decisions: The study supports evaluating the total cardiometabolic burden when deciding whether to continue or intensify long-term aspirin for secondary prevention. In some high-risk patients for bleeding, alternative strategies or closer monitoring may be appropriate. AHA Journals+1
• Patients with prior GI disease need special attention: Those with a history of peptic ulcer disease or other GI disorders — and patients who are younger men in this cohort — had larger relative bleeding risks, suggesting a lower threshold for gastroprotection or diagnostic evaluation. BioMed Central
• Do not reflexively stop aspirin during GI bleeding without specialist input: Leading gastroenterology guidance recommends careful, case-by-case decisions about withholding aspirin in the setting of acute GI bleeding; when aspirin is being used for secondary cardiovascular prevention, many guideline panels advise resuming it once hemostasis is achieved because stopping it may increase thrombotic risk. These decisions should involve both cardiology and gastroenterology as needed. American College of Gastroenterology

Practical risk-mitigation strategies

When aspirin is clearly indicated for secondary prevention but bleeding risk is elevated, clinicians commonly consider the following measures:

1. Assess and address modifiable GI risks: Test for and treat Helicobacter pylori infection in high-risk aspirin users — eradication reduces the risk of aspirin-associated peptic-ulcer bleeding. Screening is particularly relevant in older patients or those with prior peptic-ulcer disease. PMC+1
2. Consider gastroprotection: Proton-pump inhibitors (PPIs) significantly reduce upper GI bleeding risk in at-risk patients on antiplatelet therapy; recent analyses support the protective effect of PPI co-prescription in patients with ischemic disease who are at elevated bleeding risk. PPI choice and duration should reflect individual risk and drug-interaction considerations. AHA Journals
3. Review concomitant medications: Concomitant use of nonsteroidal anti-inflammatory drugs (NSAIDs), anticoagulants, or certain SSRIs can further raise bleeding risk; deprescribing or substitution may be possible in many cases. nhs.uk+1
4. Lower-dose aspirin when appropriate: For many patients with ASCVD, low-dose aspirin (e.g., 75–100 mg daily) achieves antiplatelet benefit with less bleeding risk than higher doses; dosing decisions should follow contemporary cardiology guidance. American College of Cardiology

Patient-facing guidance (how to explain it)

• Explain that aspirin reduces future heart attack and stroke risk but increases the chance of bleeding, especially in the stomach or intestines. Provide concrete signs to watch for (black/tarry stools, vomiting blood, severe abdominal pain, fainting) and clear instructions to seek urgent care if they occur. nhs.uk
• Emphasize the importance of regular medication reviews so that clinicians can reassess aspirin’s net benefit as cardiometabolic conditions change over time. AHA Journals+1

Limitations

This analysis is observational and draws from a UK population; associations do not prove causality and absolute rates may differ in other healthcare settings. The study focused on first GI-bleeding events and did not fully explore bleeding severity or downstream outcomes (e.g., mortality). Nevertheless, the long follow-up and dose–response pattern strengthen the clinical relevance of the findings. BioMed Central

Bottom line

For patients on long-term aspirin after ischaemic cardiovascular events, cardiometabolic comorbidity is not just a cardiovascular concern — it materially alters bleeding risk. Clinicians should incorporate cumulative cardiometabolic burden into shared decision-making, consider targeted GI-protective strategies (including H. pylori testing and, where appropriate, PPI co-prescription), and ensure regular reassessment of aspirin’s risk–benefit balance. BioMed Central+2PMC+2

Suggested external links (copy these anchor texts into your CMS and link to the cited sources)

1. “Association of cardiometabolic risk burden with first gastrointestinal bleeding in aspirin users — BMC Gastroenterology (UK Biobank analysis)”. BioMed Central
2. “2023 AHA/ACC Guideline for the management of patients with ASCVD (aspirin in secondary prevention)”. AHA Journals
3. “ACG clinical guidance: management of gastrointestinal bleeding and antiplatelet therapy”. American College of Gastroenterology