Should aspirin (acetylsalicylic acid) be stopped before pacemaker surgery?

Management of Aspirin Before Pacemaker Surgery

Aspirin should be discontinued 3 days before pacemaker surgery unless the patient has a high thrombotic risk that outweighs bleeding concerns. 1

Evidence-Based Approach to Perioperative Aspirin Management

Risk Stratification

The decision to continue or discontinue aspirin before pacemaker implantation should be based on:

1. Thrombotic Risk Assessment:

   • Recent coronary stent placement (especially within 3-6 months for DES or 30 days for BMS)
   • History of stroke/TIA
   • Secondary prevention for established cardiovascular disease

2. Bleeding Risk Assessment:

   • Pacemaker implantation is generally considered a procedure with moderate bleeding risk
   • Patient-specific factors (e.g., renal dysfunction, prior bleeding events)

Specific Recommendations

For Most Patients:

• Last intake of aspirin should be on D-3 (where D0 is the day of procedure) 1
• Resume aspirin as soon as hemostasis is achieved, typically within 24 hours post-procedure

For High Thrombotic Risk Patients:

• Continue aspirin throughout the perioperative period if:
  • Patient has a coronary stent placed within the last 6 months
  • Patient has had a recent stroke/TIA
  • Patient is at high risk for cardiac events 1

For Patients with Coronary Stents:

• Do not discontinue aspirin if:
  • BMS placed within 30 days
  • DES placed within 3-6 months (ideally 12 months) 1
• For patients beyond these timeframes, aspirin can be discontinued 3 days before surgery

Important Considerations

Risks of Aspirin Discontinuation

• Discontinuing aspirin can increase the risk of major adverse cardiac events by approximately three-fold in patients with established cardiovascular disease 2
• Risk is particularly high in patients with intracoronary stents 2

Risks of Continuing Aspirin

• Potential for increased bleeding during pacemaker implantation
• However, many electrophysiologists can safely perform pacemaker implantation with patients on aspirin therapy

Timing of Resumption

• Aspirin should be restarted as soon as possible after surgery when hemostasis is achieved
• Typically within 24 hours post-procedure 1

Clinical Algorithm

1. Assess thrombotic risk:

   • If patient has coronary stent placed within 30 days (BMS) or 3-6 months (DES) → continue aspirin
   • If patient has history of recent stroke/TIA → continue aspirin
   • If patient is on aspirin for secondary prevention with high cardiac risk → continue aspirin

2. If none of the above apply:

   • Discontinue aspirin 3 days before procedure 1
   • Resume aspirin within 24 hours after procedure once hemostasis is achieved

3. For urgent/emergent procedures:

   • Proceed with surgery without discontinuing aspirin if thrombotic risk outweighs bleeding risk
   • Consider additional hemostatic measures during the procedure

Common Pitfalls to Avoid

1. Discontinuing aspirin too early (>5 days before surgery) can increase thrombotic risk
2. Failing to resume aspirin promptly after surgery
3. Not considering individual patient risk factors for both thrombosis and bleeding
4. Discontinuing aspirin in patients with recent coronary stents (high risk of stent thrombosis)
5. Applying a "one-size-fits-all" approach rather than risk stratification

Remember that management decisions should be made in consultation with the proceduralist and cardiologist, particularly for patients with complex cardiovascular histories or recent stent placement.