BACKGROUND: Aged patients with coronary stents facing gastrointestinal cancer surgery are encountered more and more frequently in clinical practice, and such patients are at high risk of both bleeding and ischemia, requiring effective risk assessment. Therefore, this study will establish a prediction tool that can predict both bleeding events and major adverse cardiovascular events (MACEs). METHODS: Multicenter clinical data from 3127 gastrointestinal cancer surgery patients with a history of coronary stent implantation were utilized to establish and validate our prediction tool. We introduced the revised cardiac risk index (RCRI) score and the subsequent dual antiplatelet therapy (PRECISE-DAPT) score to be contrast. Net reclassification index (NRI) and integrated discrimination improvement (IDI) were used to interpret the strengths. Within 30 days post-surgery, we compared the bleeding events and MACEs. RESULTS: Among 3127 patients, 437 (13.9%) developed MACEs and 565 (18.1%) developed bleeding events. The MACEs model achieved good prediction performance both in the internal set (AUC: 0.924, 95% CI: 0.910-0.939) and the external set (AUC: 0.908, 95% CI: 0.880-0.937). The bleeding model also achieved good prediction performance both in the internal set (AUC: 0.862, 95% CI: 0.843-0.882) and the external set (AUC: 0.852, 95% CI: 0.818-0.886). The nomogram score greater than 131 indicates a high risk, with a postoperative MACEs incidence exceeding 23%. Similarly, the score exceeding 124 signifies a high risk, with a postoperative bleeding incidence above 21%. CONCLUSION: The novel predictive instrument provides the online risk calculator, which could accurately quantify the risk of bleeding and ischemia in patients with coronary stent undergoing gastrointestinal cancer surgery.