Teleologically, when there is bleeding, the natural response of the body is to promote clotting. This makes perfect sense if there is external injury that leads to bleeding and the response is also useful for some forms of internal “injury,” such as gastrointestinal (GI) bleeding. However, in those prone to atherosclerosis, the prothrombotic stimulus of bleeding can provoke ischemic events leading to the paradox of patients who are bleeding also being at potentially high ischemic risk.1 This mechanism is less likely to occur in a young healthy person, but in an older patient with established or silent atherosclerosis, myocardial ischemia may occur.