From the Guidelines
Stopping aspirin before eye surgery in patients with coronary stents is not recommended due to the significant risk of stent thrombosis and subsequent myocardial infarction. Patients with coronary stents should continue their aspirin therapy (typically 81-325 mg daily) even during eye surgery, as the risk of stent thrombosis and subsequent myocardial infarction outweighs the bleeding risk during most ophthalmic procedures 1. For patients with drug-eluting stents, the risk is particularly high within the first 6-12 months after placement, while bare metal stents carry elevated risk within the first month.
Key Considerations
- The decision to stop or continue aspirin therapy should involve a multidisciplinary approach between the ophthalmologist, anesthesiologist, and cardiologist to balance thrombotic and hemorrhagic risks 1.
- If bleeding concerns exist, consider maintaining aspirin but temporarily discontinuing other antiplatelet agents like clopidogrel, prasugrel, or ticagrelor, in consultation with the patient's cardiologist 1.
- Aspirin should be continued perioperatively, and if it has to be discontinued, it should be resumed as early as possible after the invasive procedure, if possible, to minimize the risk of stent thrombosis and myocardial infarction 1.
Management of Antiplatelet Therapy
- Non-cardiac elective procedures should be postponed until completion of the full course of dual antiplatelet therapy (DAPT) when it does not pose a major life-threatening or functional risk to the patient 1.
- If DAPT has to be discontinued perioperatively, it should be resumed early, if possible within 24 to 72 hours after surgery, given the increased thrombotic risk 1.
- A bridging strategy with an intravenous antiplatelet agent such as tirofiban or cangrelor can be considered on a case-by-case basis after multidisciplinary discussion, in exceptional situations associated with a high risk of bleeding and thrombosis 1.
From the Research
Risks of Myocardial Infarction after Stopping Aspirin in Adult Patients with Stents for Eye Surgery
- The risk of myocardial infarction after stopping aspirin in adult patients with stents is a significant concern, as aspirin is often used to prevent further thrombotic events in patients with prior acute coronary syndrome (ACS) or stroke 2.
- Stopping aspirin therapy can lead to a rebound effect of platelet responsiveness, increasing the risk of thrombosis, particularly in patients with coronary stents 2, 3.
- Studies have shown that discontinuing antiplatelet therapy, including aspirin, before surgery can increase the risk of major adverse cardiac events (MACE), including myocardial infarction, cardiac death, and stroke 4, 5.
- The risk of MACE is higher in patients who discontinue antiplatelet therapy, with one study showing a 7.5% incidence of MACE in patients who stopped antiplatelet therapy compared to 0.3% in those who continued therapy 4.
- Aspirin should be continued perioperatively in the majority of surgical operations, unless there is a high risk of bleeding, in which case alternative antiplatelet regimens may be considered 3, 5.
Management of Antiplatelet Therapy in Patients with Coronary Stents Undergoing Surgery
- Current guidelines recommend continuing aspirin therapy perioperatively, unless there is a high risk of bleeding, and delaying non-urgent surgery for at least 6 weeks after bare metal stent implantation and 6-12 months after drug-eluting stent implantation 3.
- A consensus document from Italian cardiological, surgical, and anaesthesiological societies provides practical recommendations for the perioperative management of antiplatelet therapy in patients with coronary stents undergoing surgery, including the use of short-acting intravenous glycoprotein IIb/IIIa inhibitors in selected patients at high risk for both bleeding and ischemic events 5.
- The use of clopidogrel plus aspirin has been shown to reduce the risk of myocardial infarction and ischemic stroke, but increases the risk of major and minor bleeding compared to aspirin alone 6.