Aspirin Management in Post-CABG Patients Before Subsequent Surgery
In patients with a history of CABG who are on aspirin, continue aspirin through the perioperative period for subsequent noncardiac surgery, as the cardiovascular benefits of uninterrupted aspirin therapy outweigh the modest increase in bleeding risk in most surgical procedures. 1
Rationale for Continuing Aspirin
Post-CABG patients require lifelong aspirin (75-100 mg daily) to maintain graft patency and prevent thrombotic complications, with aspirin improving saphenous vein graft patency particularly during the first postoperative year. 1, 2, 3
Continuation of aspirin through the perioperative period is associated with reduced risk of myocardial infarction without increasing mortality, though it does increase perioperative bleeding and transfusion requirements. 1
The 2023 ACC/AHA guidelines explicitly recommend that patients already taking aspirin preoperatively should continue it through the perioperative period for subsequent surgeries. 1
Evidence Supporting Continuation
Early observational data demonstrated an association between preoperative aspirin administration and reduced in-hospital death in CABG patients. 1
Meta-analyses show that continuation of aspirin until surgery increases bleeding (approximately 132 mL additional blood loss) and transfusion requirements, but does not increase the likelihood of surgical reoperation for bleeding. 1, 4
The 2007 ACC/AHA perioperative guidelines state that aspirin monotherapy need not be routinely discontinued for elective noncardiac surgery, noting that while aspirin may increase procedural bleeding frequency (relative risk 1.5), it does not increase severity of bleeding complications or perioperative mortality due to bleeding. 1
Specific Surgical Considerations
Most Noncardiac Surgeries
- Continue aspirin 75-100 mg daily through the perioperative period for the vast majority of noncardiac surgical procedures. 1
High Bleeding Risk Procedures
- Consider individualized assessment for procedures with prohibitive bleeding risk, such as intracranial neurosurgery or transurethral prostatectomy, where aspirin discontinuation may be warranted. 1
- In these rare cases, discontinue aspirin 5-7 days before surgery and resume as soon as hemostasis is secured postoperatively. 1
Cardiac and Vascular Surgery
- For repeat cardiac surgery or vascular procedures, continue aspirin through the perioperative period, as these patients benefit from continued antiplatelet therapy and surgeons in these specialties routinely manage aspirin-related bleeding. 1
Practical Algorithm
Identify the patient's current aspirin regimen (typically 75-100 mg daily in post-CABG patients). 1, 2, 3
Assess the planned surgical procedure's bleeding risk:
For patients at high ischemic risk (recent CABG within 1 year, complex grafting, history of graft failure), strongly favor continuing aspirin even in moderate bleeding risk procedures. 1, 2
If aspirin must be stopped, resume within 24-48 hours postoperatively once hemostasis is secured. 1, 3
Bleeding Risk Mitigation
Add a proton pump inhibitor for gastrointestinal bleeding prophylaxis in patients on aspirin, especially those with history of GI bleeding, elderly patients, or those on chronic NSAIDs. 1, 2
Low-dose aspirin (75-100 mg daily) minimizes bleeding risk while maintaining efficacy for graft patency and cardiovascular protection. 1, 3
Critical Pitfalls to Avoid
Do not routinely discontinue aspirin for elective noncardiac surgery in post-CABG patients, as the thrombotic risk of aspirin withdrawal typically exceeds the bleeding risk. 1
Avoid stopping aspirin in patients within the first year after CABG unless absolutely necessary, as this is the critical period for graft patency. 3
Do not confuse guidance for dual antiplatelet therapy (aspirin plus P2Y12 inhibitor) with aspirin monotherapy - P2Y12 inhibitors like clopidogrel should be stopped 5-7 days before elective surgery, but aspirin should continue. 1