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Timing of Antiplatelet and Anticoagulant Therapy Resumption Following Gastrointestinal Bleeding: A Systematic Review
Yihang Liu1, Yaxin Hu2, Shangzheng Song1
1Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore; Centre of AI in Medicine, Nanyang Technological University, Singapore, Singapore.
Background & Aims:
Gastrointestinal bleeding is a major complication in patients receiving antithrombotic therapy. Following gastrointestinal bleeding, clinicians face a critical dilemma: resuming therapy risks rebleeding, whereas discontinuation increases thrombotic events and mortality. This meta-analysis aimed to quantify the risks and benefits of antithrombotic therapy resumption vs discontinuation following gastrointestinal bleeding, and to evaluate the impact of resumption timing on recurrent gastrointestinal bleeding, major vascular events, and all-cause mortality.
Methods:
We searched Embase, Scopus, PubMed, Web of Science, and Cochrane Library from inception to September 2025 for studies comparing antithrombotic therapy resumption vs delayed resumption or discontinuation after gastrointestinal bleeding. This review was registered with PROSPERO (CRD420251141360).
Results:
Twenty-one studies were included. Antiplatelet therapy resumption reduced major vascular events (hazard ratio, 0.70; 95% confidence interval, 0.60-0.83; absolute risk difference, -3.6%) and mortality (hazard ratio, 0.44; 95% confidence interval, 0.26-0.76; absolute risk difference, -10.0%), but increased recurrent gastrointestinal bleeding (hazard ratio, 1.42; 95% confidence interval, 1.09-1.84; absolute risk difference, +2.2%). Similarly, anticoagulant therapy resumption reduced major vascular events (hazard ratio, 0.45; 95% confidence interval, 0.34-0.58; absolute risk difference, -7.0%) and mortality (hazard ratio, 0.53; 95% confidence interval, 0.43-0.65; absolute risk difference, -11.1%), but increased recurrent gastrointestinal bleeding (hazard ratio, 1.59; 95% confidence interval, 1.38-1.83; absolute risk difference, +2.6%). Notably, early resumption of both antiplatelet therapy and anticoagulant therapy within 7 days significantly reduced major vascular events (hazard ratio, 0.39; 95% confidence interval, 0.19-0.78; absolute risk difference, -11.4%) but increased recurrent gastrointestinal bleeding (hazard ratio, 1.49; 95% confidence interval, 1.18-1.89; absolute risk difference, +2.7%), with no significant difference in mortality (hazard ratio, 0.78; 95% confidence interval, 0.29-2.10; absolute risk difference, -4.7%).
Conclusions:
Both antiplatelet therapy and anticoagulant therapy resumption after gastrointestinal bleeding provide substantial clinical benefits despite increased recurrent gastrointestinal bleeding risk. Early resumption (≤7 days) offers favorable benefit-risk balance.
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