What are the recommendations for aspirin (acetylsalicylic acid) in a patient who had a hemorrhagic stroke six months ago, has a history of coronary disease, and is now undergoing non-cardiac surgery?

Management of Aspirin in a Patient with History of Hemorrhagic Stroke and Coronary Disease Undergoing Non-Cardiac Surgery

In a patient with history of hemorrhagic stroke six months ago and coronary disease undergoing non-cardiac surgery, aspirin should be discontinued due to the high risk of bleeding complications outweighing the potential cardiovascular benefits.

Risk Assessment Framework

Bleeding Risk Considerations

• Recent hemorrhagic stroke: A history of hemorrhagic stroke within the past 6 months represents a significant risk factor for recurrent bleeding, especially with antiplatelet therapy
• Surgical bleeding risk: Non-cardiac surgery carries variable bleeding risk depending on the specific procedure

Cardiovascular Risk Considerations

• History of coronary disease and CABG: Indicates elevated baseline cardiovascular risk
• Time since coronary intervention: CABG without recent stenting has different antiplatelet requirements than recent PCI

Evidence-Based Recommendations

Primary Recommendation

According to the 2014 ACC/AHA Perioperative Guidelines, in patients undergoing elective non-cardiac surgery who have not had previous coronary stenting, initiation or continuation of aspirin is not beneficial 1. This recommendation carries a Class III (No Benefit) recommendation with Level of Evidence B.

Special Considerations for This Patient

1. Recent hemorrhagic stroke history:

   • This represents a significant contraindication to perioperative aspirin therapy
   • The 6-month timeframe is still within the high-risk period for recurrent hemorrhage

2. Type of coronary disease:

   • For patients with CABG (without recent stenting), the cardiovascular benefit of perioperative aspirin is less compelling than for patients with recent coronary stenting
   • The guidelines specifically state that aspirin may be reasonable only "when the risk of increased cardiac events outweighs the risk of increased bleeding" 1

3. Risk-benefit analysis:

   • The risk of perioperative bleeding complications in a patient with recent hemorrhagic stroke likely outweighs the potential cardiovascular benefit of continuing aspirin

Management Algorithm

1. Preoperative assessment:

   • Determine exact timing of previous hemorrhagic stroke (6 months ago)
   • Confirm coronary disease history and type of intervention (CABG)
   • Verify absence of coronary stents (which would require different management)

2. Antiplatelet management:

   • Discontinue aspirin at least 5-7 days before surgery
   • Do not substitute with other antiplatelet agents

3. Postoperative management:

   • Consider resuming aspirin 24-48 hours after surgery if:
     • No evidence of postoperative bleeding
     • Hemostasis is adequate
     • No neurological complications

4. Monitoring:

   • Close monitoring for both thrombotic and bleeding complications
   • Vigilance for signs of cardiac ischemia during the perioperative period

Important Caveats

• If the patient has had coronary stenting (not mentioned in the case), management would be different and might require continuation of aspirin throughout surgery
• If surgery is urgent/emergent, the risk-benefit assessment should be reconsidered with the surgical team
• A multidisciplinary approach involving cardiology, neurology, anesthesiology, and surgery is essential for optimal management

The decision to withhold aspirin in this case is based on the significant risk of recurrent hemorrhagic stroke, which outweighs the potential cardiovascular benefit in a patient without recent coronary stenting.