Question 4

after the ulcer has healed, simply resume the aspirin therapy 

Incorrect. Patients who develop ulcer bleeding with taking aspirin are at risk of developing subsequent gastrointestinal bleeds.  While aspirin should be continued indefinitely for prevention of cardiovascular events in patients for whom its potential benefits outweigh its potential harms, adding a proton-pumpinhibitor can reduce future gastrointestinal bleed risk.

after the ulcer has healed, resume aspirin and add a proton-pump inhibitor

Correct. A trial of patients who developed ulcer bleeding while taking aspirin found that the combination of aspirin plus a proton pump inhibitor (esomeprazole) was significantly more effective than clopidogrel alone at reducing the risk of re-bleeding.

after the ulcer has healed, change to clopidogrel (Plavix)

Incorrect. While the American Heart Association and the American College of Cardiology guidelines for the management of patients with acute ST-segment elevation myocardial recommend clopidogrel for patients who cannot take aspirin because of major gastrointestinal intolerance, this recommendation is based onthe CAPRIE trial in which aspirin-treated patients were given 325 mg, which is more than is commonly used in current practice.  It is therefore unknown whether clopidogrel is safer than the usual lower doses of aspirin. A trial of patients who developed ulcer bleeding while taking aspirin found that the combination of aspirin plus a proton pump inhibitor (esomeprazole) was significantly more effective than clopidogrel alone at reducing the risk of re-bleeding.

after the ulcer has healed, change to clopidogrel (Plavix) and add a proton-pump inhibitor

Incorrect.  Combination treatment with clopidogrel and proton-pump inhibitors is generally not recommended because of a potential interaction, which may reduce the effectiveness of clopidogrel in some patients.