When to continue aspirin in a preoperative inpatient with coronary artery disease (CAD)?

Perioperative Aspirin Management in Patients with Coronary Artery Disease

In patients with coronary artery disease undergoing noncardiac surgery, aspirin (75-100 mg) should be continued perioperatively when the risk of cardiac events outweighs the risk of bleeding. 1

Decision Algorithm for Perioperative Aspirin Management

High-Risk Patients (Continue Aspirin)

• Patients with prior PCI:

  • Continue aspirin (75-100 mg) perioperatively 1
  • For patients with recent PCI (<30 days for BMS or <3 months for DES), continue DAPT unless bleeding risk is prohibitive 1
  • For patients on oral anticoagulation who must discontinue it, substitute with aspirin perioperatively 1

• Patients with CAD but no PCI:

  • Continue aspirin in selected patients when cardiac risk outweighs bleeding risk 1, 2
  • High cardiac risk factors include: recent MI, cerebrovascular disease, peripheral arterial disease, or multiple cardiovascular risk factors 2

Timing Considerations for Surgery After PCI

• For DES-PCI placed for ACS: Delay elective surgery ≥12 months 1
• For DES-PCI placed for CAD: Delay elective surgery ≥6 months 1
• For time-sensitive surgery with DES-PCI: May consider surgery ≥3 months after PCI if benefits outweigh risks 1
• For recent (<30 days) BMS or DES-PCI: Elective surgery requiring antiplatelet interruption is potentially harmful 1

Surgery-Specific Considerations

• High bleeding risk surgeries (e.g., intracranial neurosurgery): May require aspirin discontinuation 2
• Carotid endarterectomy: Consider continuing aspirin 2
• Urgent/emergent surgery: Continue aspirin in patients with coronary stents 2

Management of Dual Antiplatelet Therapy (DAPT)

• If P2Y12 inhibitor must be discontinued, continue aspirin throughout the perioperative period 1, 2
• Restart P2Y12 inhibitor as soon as possible after surgery 2
• For time-sensitive surgery within 30 days of BMS-PCI or <3 months of DES-PCI, continue DAPT unless bleeding risk outweighs stent thrombosis prevention 1
• In select high thrombotic risk patients, consider perioperative bridging with IV antiplatelet therapy if surgery cannot be deferred <6 months after DES or <30 days after BMS 1

Practical Considerations

• Aspirin dosing: 75-100 mg is recommended to minimize bleeding risk while maintaining efficacy 1
• If aspirin is discontinued: Resume as early as possible postoperatively, ideally same day 2
• Monitoring: Close observation for both bleeding complications and cardiovascular events 2
• Inform surgical team: Ensure awareness of continued aspirin therapy to prepare appropriate hemostatic measures 2

Bleeding Risk Considerations

While continuing aspirin may increase the risk of perioperative bleeding, this risk is generally outweighed by the cardiovascular benefits in high-risk patients. Studies show that low-dose aspirin (≤100 mg/day) minimizes bleeding risk 3.

Caveats and Pitfalls

1. Avoid abrupt discontinuation in high-risk patients as this may lead to a rebound hypercoagulable state 2
2. Don't automatically discontinue aspirin in all surgical patients without considering cardiac risk
3. Don't assume all surgeries carry the same bleeding risk - tailor approach based on specific procedure
4. Avoid delaying urgent surgeries unnecessarily in patients on aspirin therapy
5. Don't forget to restart aspirin as soon as possible postoperatively if discontinued

The 2024 AHA/ACC guidelines provide the most current evidence-based recommendations for perioperative aspirin management, emphasizing the importance of continuing aspirin in high-risk patients while considering the specific surgical bleeding risk in the decision-making process.