How should aspirin (acetylsalicylic acid) be managed in patients undergoing surgery?

From the Guidelines

Aspirin should be continued in patients undergoing surgery who are taking it for secondary prevention, but its use in primary prevention should be carefully considered based on the individual's risk of bleeding and cardiac events. The management of aspirin in surgical patients is a complex issue that requires careful consideration of the patient's underlying medical conditions, the type of surgery, and the risk of bleeding and cardiac events 1. For patients taking aspirin for secondary prevention, such as those with a history of heart attack, stroke, or stent placement, the benefits of continuing aspirin throughout the perioperative period generally outweigh the risks 1. However, for patients taking aspirin for primary prevention, the decision to continue or discontinue aspirin should be based on the individual's risk of bleeding and cardiac events, as well as the type of surgery being performed 1. Some studies suggest that aspirin may increase the risk of bleeding in certain types of surgery, such as neurosurgery or posterior eye surgery, and therefore may need to be temporarily stopped in these cases 1. The dose of aspirin typically remains the same as the patient's regular regimen, usually 81-325 mg daily, and should be resumed 24-48 hours after surgery once hemostasis is achieved 1. It's also important to note that the decision to continue or discontinue aspirin should be made in consultation with the patient's healthcare team, including the surgeon, anesthesiologist, and cardiologist, and should take into account the individual's unique medical history and risk factors 1. In urgent surgeries, the surgical team should be informed of the patient's aspirin use, and platelet transfusion may be considered if significant bleeding occurs 1. Overall, the key to managing aspirin in surgical patients is to carefully weigh the benefits and risks of continuing or discontinuing aspirin, and to make decisions based on the individual patient's unique needs and circumstances. Some key points to consider when managing aspirin in surgical patients include:

• The patient's underlying medical conditions, such as a history of heart attack, stroke, or stent placement
• The type of surgery being performed, and the associated risk of bleeding and cardiac events
• The patient's individual risk factors, such as age, blood pressure, and kidney function
• The potential benefits and risks of continuing or discontinuing aspirin, including the risk of bleeding and cardiac events
• The need for close communication and collaboration between the patient's healthcare team, including the surgeon, anesthesiologist, and cardiologist.

From the Research

Aspirin Management in Patients Undergoing Surgery

• The management of aspirin in patients undergoing surgery is a complex issue that requires a case-by-case risk-benefit analysis 2, 3.
• Patients taking aspirin for primary prevention of cardiovascular disease should likely discontinue it during the perioperative period, especially when there is a high risk of bleeding 3.
• Patients with established cardiovascular disease, but without a coronary stent, should likely continue aspirin during the perioperative period unless undergoing closed-space surgery 3.
• Patients with a history of coronary stenting also likely need aspirin continuation throughout the perioperative period for non-closed space procedures 3, 4.

Risks of Aspirin Withdrawal

• The cessation of aspirin can cause a platelet rebound phenomenon and prothrombotic state leading to major adverse cardiovascular events 5.
• Aspirin withdrawal syndrome may significantly increase the risk of a major thromboembolic complication when aspirin is held preoperatively 5.
• The risk of perioperative bleeding while continuing aspirin is minimal, as compared with the concomitant thromboembolic risks associated with aspirin withdrawal 5, 6.

Decision-Making for Aspirin Management

• Perioperative clinicians need to balance the risks of ceasing aspirin before surgery against its continuation during the perioperative interval using a patient-specific strategy 3, 5.
• The decision to stop or continue aspirin treatment should be based on individual patient factors, such as the type of surgery, the patient's cardiovascular risk, and the risk of bleeding 2, 4.
• Further studies are needed to provide clear guidance on the management of aspirin in patients undergoing surgery 2, 3, 6.