What is the recommended management of aspirin (acetylsalicylic acid) in a patient with a history of stroke undergoing surgery?

From the Guidelines

For patients with a history of stroke on aspirin, it is generally recommended to continue aspirin through the perioperative period, rather than discontinuing it, to minimize the risk of recurrent stroke. This approach is based on the principle of balancing the risk of thrombotic events against bleeding concerns, as supported by guidelines such as those from the American Heart Association/American Stroke Association 1.

When considering the management of aspirin in patients with a history of stroke undergoing surgery, several factors come into play, including the type of surgery, the patient's individual risk of bleeding, and the time elapsed since the stroke.

• The risk of ischemic stroke is a significant concern in the perioperative period, particularly in patients with a history of stroke or transient ischemic attack (TIA).
• Aspirin irreversibly inhibits platelet function, and its effects last for the lifespan of the platelet, which is approximately 7-10 days.
• For most surgical procedures, the risk of thrombotic events outweighs the bleeding risk, supporting the continuation of aspirin.
• However, for high bleeding risk procedures such as neurosurgery, spinal surgery, or certain ophthalmologic procedures, a more cautious approach may be necessary, potentially involving the temporary discontinuation of aspirin 7-10 days before surgery and resuming it 24-48 hours postoperatively when hemostasis is achieved.

The decision to modify aspirin management should be made collaboratively between the surgeon, anesthesiologist, and the patient's neurologist or stroke specialist, taking into account the individual's specific stroke history, time since the event, and the bleeding risk of the planned procedure, as suggested by guidelines such as the 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack 1.

From the Research

Aspirin Management in Patients with a History of Stroke Undergoing Surgery

• The management of aspirin in patients with a history of stroke undergoing surgery is complex and depends on various factors, including the type of surgery, the patient's cardiovascular risk, and the risk of bleeding 2.
• Patients taking aspirin for the primary prevention of cardiovascular disease should likely discontinue it during the perioperative period, especially when there is a high risk of bleeding 2.
• Patients with established cardiovascular disease, including those with a history of stroke, but without a coronary stent, should likely continue aspirin during the perioperative period unless undergoing closed-space surgery 2.
• The decision to hold or continue aspirin should be made on a patient-specific basis, taking into account the individual's risk of bleeding and cardiovascular events 2.
• There is limited data on the optimal management of aspirin in patients with a history of stroke undergoing surgery, and further studies are needed to provide clear guidance 2.

Risks and Benefits of Aspirin Therapy

• Aspirin therapy is associated with a reduced risk of recurrent stroke and major adverse cardiovascular events, but also increases the risk of bleeding 3, 4, 5, 6.
• The benefits of aspirin therapy must be weighed against the risks, particularly in patients undergoing surgery, where the risk of bleeding may be increased 2.
• Alternative antiplatelet therapies, such as clopidogrel, may be considered in patients who are at high risk of bleeding or who have experienced a breakthrough stroke while on aspirin 3, 5, 6.

Clinical Considerations

• Patients with a history of stroke should be carefully evaluated before undergoing surgery, and the decision to hold or continue aspirin should be made in consultation with a multidisciplinary team 2.
• The use of aspirin and other antiplatelet therapies should be individualized based on the patient's specific clinical characteristics and risk factors 2, 3, 4, 5, 6.