Should aspirin be held preoperatively in a 79-year-old patient with cataract surgery, hypertension, diabetes mellitus, and hyperlipidemia, taking amlodipine, metoprolol, valsartan, and Paxil (paroxetine), with a recent history of carotid artery endarterectomy?

From the Guidelines

Aspirin should not be held prior to cataract surgery in this 79-year-old patient with hypertension, diabetes, hyperlipidemia, and recent carotid endarterectomy. The patient can continue taking aspirin throughout the perioperative period for cataract surgery, as the risk of thrombotic events, especially with recent carotid endarterectomy, outweighs the minimal bleeding risk associated with cataract surgery 1.

According to the 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline, aspirin is recommended before carotid endarterectomy (CEA) and may be continued indefinitely postoperatively, with a Level of Evidence: A 1. This guideline supports the continuation of aspirin in patients with a history of carotid endarterectomy, highlighting the importance of long-term prophylaxis against ischemic cardiovascular events.

Key considerations for the patient's perioperative management include:

• Continuing all medications, including amlodipine, metoprolol, valsartan, and Paxil, without interruption
• Informing the ophthalmologist about all medications, particularly the aspirin and recent carotid surgery, to prepare for any minimal increased bleeding risk
• Following specific instructions from the ophthalmologist regarding eye drops before and after surgery
• Arriving at the surgical center with a responsible adult who can provide transportation home after the procedure

The ophthalmologist will use techniques to minimize any potential bleeding, such as careful wound construction and possibly topical anesthesia. Overall, the benefits of continuing aspirin therapy in this patient outweigh the risks, and it is essential to prioritize the patient's cardiovascular health while minimizing the risk of bleeding complications during cataract surgery 1.

From the Research

Preoperative Clearance for Cataract Surgery

• The patient is a 79-year-old with hypertension, diabetes, hyperlipidemia, and a recent carotid artery endarterectomy.
• The patient is currently taking amlodipine, metoprolol, valsartan, Paxil, and aspirin.

Aspirin Therapy

• 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.
• The study by 3 found that perioperative antiplatelet therapy was significantly associated with a decreased in-hospital stroke and death risk.
• However, the study by 4 suggests that dual antiplatelet therapy may be associated with an increased risk of bleeding and decreased risk of stroke following carotid endarterectomy.
• 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.

Recommendations

• Based on the available evidence, it is recommended that aspirin therapy be continued in the perioperative period for the patient undergoing cataract surgery, given the recent carotid artery endarterectomy 2, 3, 5.
• However, the decision to continue or hold aspirin therapy should be made in consultation with the patient's cardiologist or primary care physician, taking into account the patient's individual risk factors and medical history.
• The study by 4 suggests that the benefits of dual antiplatelet therapy may be outweighed by the increased risk of bleeding, and therefore, aspirin monotherapy may be sufficient.