How to manage a patient with chronic thrombocytopenia, on aspirin (acetylsalicylic acid), with a pacemaker (permanent artificial cardiac pacemaker), who is scheduled for surgery?

From the Guidelines

For a patient with chronic thrombocytopenia on aspirin with a pacemaker who needs surgery, the most recent and highest quality evidence suggests that aspirin should not be discontinued preoperatively when prescribed for secondary prevention, as the risk of cardiovascular events outweighs the risk of bleeding 1. The management of such a patient involves several key considerations to balance the risk of bleeding against the risk of thrombotic events.

• Obtain a complete blood count to assess current platelet levels, with platelet transfusion recommended if counts are below 50,000/μL for most surgeries or below 100,000/μL for neurosurgical or ophthalmological procedures.
• Consult with cardiology regarding pacemaker management; typically, the device should be interrogated before surgery and reprogrammed to asynchronous mode (VOO or DOO) if electrocautery will be used during the procedure, as recommended by guidelines such as those from the American College of Cardiology/American Heart Association 1.
• After surgery, the pacemaker should be re-evaluated and returned to its original settings.
• Consider bridging anticoagulation with short-acting agents if the patient has additional cardiovascular risk factors, although the decision to bridge should be made on a case-by-case basis, taking into account the patient's individual risk factors for thrombosis and bleeding, as suggested by studies such as the one published in Chest in 2012 1.
• The anesthesiologist should be informed about the pacemaker and thrombocytopenia to guide monitoring decisions, ensuring that the patient receives appropriate care during the perioperative period. This approach is supported by the most recent guidelines, including those from the French Working Group on Perioperative Haemostasis and the French Study Group on Thrombosis and Haemostasis, which emphasize the importance of balancing the risks of bleeding and thrombosis in patients undergoing surgery 1.

From the Research

Patient Considerations

• The patient has chronic thrombocytopenia, which is a condition characterized by a low platelet count in the blood 2.
• The patient is on aspirin, which is an antiplatelet agent that can increase the risk of bleeding, particularly in patients with thrombocytopenia 3, 4.
• The patient has a pacemaker, which is a medical device that uses electrical impulses to regulate the heartbeat.

Aspirin Management

• The decision to stop or continue aspirin therapy before surgery should be made on a case-by-case basis, taking into account the patient's individual risk factors and medical history 3, 4.
• Studies have shown that stopping aspirin therapy 7-10 days before surgery can reduce the risk of bleeding complications, but the optimal timing for stopping aspirin is not well established 3.
• In patients with coronary stents, stopping aspirin therapy can increase the risk of adverse cardiac events, and the decision to stop aspirin should be made in consultation with a cardiologist 4.

Thrombocytopenia Management

• Thrombopoietin receptor agonists (TPO-RAs) are a class of medications that can stimulate platelet production and may be used to manage thrombocytopenia 2.
• The choice of TPO-RA and the dosing regimen should be individualized based on the patient's response to treatment and the presence of any adverse effects 2.
• Cytoreductive therapy may also be used to manage thrombocytopenia, particularly in patients with essential thrombocythemia 5.

Surgical Considerations

• The patient's low platelet count and aspirin therapy should be taken into account when planning surgery, and the surgical team should be prepared to manage any bleeding complications that may arise 3, 4.
• The use of TPO-RAs or other medications to stimulate platelet production may be considered before surgery to reduce the risk of bleeding complications 2.