Yes, aspirin should be continued right before CABG surgery
Aspirin (100-325 mg daily) should be administered to CABG patients preoperatively and continued through the perioperative period 1, 2, 3. This is a Class I recommendation with Level of Evidence B from multiple ACC/AHA guidelines.
Key Evidence Supporting Preoperative Aspirin
The guideline evidence is unequivocal and consistent across multiple iterations:
- Continue aspirin preoperatively: All major guidelines from 2011-2023 recommend aspirin administration to CABG patients before surgery 1, 4, 2, 3
- Postoperative initiation if not given preoperatively: If aspirin wasn't started preoperatively, it should be initiated within 6 hours postoperatively 1, 5
- Continue indefinitely: Aspirin should be continued long-term after CABG to reduce saphenous vein graft closure and adverse cardiovascular events 1
The 2023 AHA/ACC performance measures explicitly state that patients should either: (1) continue aspirin through the perioperative period if already taking it, or (2) start aspirin within 6 hours postoperatively 5.
Bleeding Risk vs. Mortality Benefit
While aspirin does modestly increase perioperative bleeding and transfusion requirements, this does not translate to increased surgical reoperation or mortality 5. The guidelines acknowledge this trade-off but firmly recommend continuation because:
- Preoperative aspirin reduces operative morbidity and mortality 2, 3
- The bleeding increase is modest and manageable 5
- Aspirin improves vein graft patency and reduces ischemic complications 5
- Research shows aspirin administration ≤24 hours before CABG reduces 30-day mortality by 75% and major adverse cardiac events by 57% 6
Dosing Considerations
The guidelines specify 100-325 mg daily as the evidence-based dose range 1, 2. However, the 2023 performance measures clarify that 81 mg daily is acceptable in clinical practice, as this lower dose is associated with less bleeding while meeting the measure requirements 5.
Critical Distinction: Aspirin vs. Other Antiplatelet Agents
This recommendation applies ONLY to aspirin. Other antiplatelet agents must be stopped:
- Clopidogrel and ticagrelor: Discontinue ≥5 days before elective CABG (≥24 hours for urgent CABG) 1, 2
- Prasugrel: Discontinue ≥7 days before elective CABG 1, 2
- GP IIb/IIIa inhibitors: Discontinue 2-4 hours (eptifibatide/tirofiban) or 12 hours (abciximab) before surgery 1
The European guidelines (2019) also support continuing aspirin perioperatively for CABG 7.
Common Pitfall to Avoid
Do not stop aspirin out of excessive bleeding concerns. The evidence shows that preoperative aspirin use is associated with decreased mortality without significant increase in hemorrhage requiring reoperation 8. Recent data confirms that aspirin given within 6 hours of CABG does not increase bleeding complications 9.
The only exceptions are documented medical contraindications such as aspirin allergy or prohibitive bleeding risk 5.