From the Guidelines
Aspirin should not be held before cataract surgery in this 79-year-old patient with a history of recent carotid artery endarterectomy, as the risk of thrombotic events outweighs the minimal increased risk of bleeding during the operation. The patient's recent carotid endarterectomy indicates a need for continued antiplatelet therapy, and aspirin is recommended to be continued indefinitely postoperatively 1. Given the patient's medical history, including hypertension, diabetes, and hyperlipidemia, it is crucial to balance the risk of bleeding with the risk of thrombotic events.
The patient can safely continue taking aspirin through the perioperative period for cataract surgery, which is considered a low bleeding risk procedure. The surgeon will use techniques to minimize any bleeding risk, such as careful wound construction and possibly topical vasoconstrictors.
- The patient should continue their other medications, including amlodipine, metoprolol, valsartan, and Paxil, without interruption before surgery.
- The patient should be instructed to take all regular medications on the morning of surgery with a small sip of water.
- The patient should bring a list of all medications to the surgical center on the day of the procedure. The American College of Cardiology Foundation/American Heart Association task force on practice guidelines recommends aspirin (81 to 325 mg daily) to be continued indefinitely postoperatively after carotid endarterectomy 1.
From the Research
Perioperative Aspirin Management for Carotid Endarterectomy
- The decision to hold aspirin in a 79-year-old patient undergoing cataract surgery who has recently undergone carotid artery endarterectomy and is on aspirin, amlodipine, metoprolol, valsartan, and Paxil, should be based on the current medical evidence.
- According to the study by 2, low-dose aspirin (75 to 325 mg) should be continued throughout the perioperative period for patients who have undergone carotid endarterectomy, as there is no evidence that higher doses confer additional benefit.
- The study by 3 found that perioperative antiplatelet therapy was significantly associated with a decreased in-hospital stroke and death risk, and that dual antiplatelet therapy was associated with a lower risk of death alone, but with a higher risk of secondary bleeding requiring reoperation.
- The ACE Trial Collaborators study 4 found that the risk of stroke, myocardial infarction, and death within 30 days and 3 months of endarterectomy is lower for patients taking 81 mg or 325 mg acetylsalicylic acid daily than for those taking 650 mg or 1300 mg.
- The study by 5 found that perioperative use of aspirin for patients undergoing carotid endarterectomy is associated with a lower risk of cardiac and neurological events without significant increase of postoperative bleeding necessitating revision.
Considerations for Aspirin Management
- The patient's recent carotid artery endarterectomy and current aspirin therapy should be taken into account when deciding whether to hold aspirin for cataract surgery.
- The studies suggest that continuing low-dose aspirin throughout the perioperative period may be beneficial for patients who have undergone carotid endarterectomy.
- However, the decision to hold aspirin should be made on a case-by-case basis, considering the patient's individual risk factors and medical history.
- It is essential to weigh the benefits of continuing aspirin against the potential risks of bleeding complications during cataract surgery.
- The study by 6 discusses the current consensus and controversies in carotid endarterectomy, but does not provide specific guidance on perioperative aspirin management for cataract surgery.