Should Acetylsalicylic acid (Aspirin) be withheld prior to surgery?

From the Guidelines

Aspirin should be withheld before surgery for patients taking it for primary prevention, but for those taking it for secondary prevention, the decision to continue or stop aspirin should be made on a case-by-case basis, considering the risk of bleeding versus the risk of cardiac events. When considering the management of antiplatelet therapy in patients undergoing elective invasive procedures, the French working group on perioperative haemostasis (GIHP) and the French study group on thrombosis and haemostasis (GFHT) propose that aspirin should be discontinued preoperatively when prescribed for primary prevention 1. However, for patients taking aspirin for secondary prevention, such as those with a history of cardiovascular events, aspirin should not be discontinued preoperatively, except for procedures with a high risk of bleeding 1. The decision to stop or continue aspirin should be made by the surgical team in consultation with the patient's cardiologist, taking into account the individual patient's risk factors and the type of surgery being performed. Some key points to consider include:

• Aspirin should not be initiated in patients not already taking it to reduce the risk of perioperative cardiovascular events before non-cardiac surgery, except for carotid endarterectomy 1.
• For patients treated with monotherapy with a P2Y12 inhibitor and scheduled for intermediate-risk surgery, the P2Y12 inhibitor should be replaced by aspirin with a daily dose of 75 to 100 mg 1.
• Antiplatelet therapy, if discontinued, should be resumed as soon as possible, according to the risk of postoperative bleeding, in patients who have an indication for long-term APA monotherapy 1. It's also important to note that aspirin irreversibly inhibits platelet function, and it takes about 7-10 days for the body to produce enough new platelets to restore normal clotting function, which is why patients should never stop aspirin on their own without medical guidance 1.

From the Research

Aspirin Management Prior to Surgery

• The decision to withhold aspirin prior to surgery depends on various factors, including the type of surgery, patient's cardiovascular risk, and the potential benefits and risks of aspirin therapy 2.
• Patients taking aspirin for primary prevention of cardiovascular disease may need to discontinue it during the perioperative period, especially if there is a high risk of bleeding 2.
• However, patients with established cardiovascular disease, such as coronary artery disease, cerebrovascular disease, or peripheral artery disease, may benefit from continuing aspirin therapy during the perioperative period 2, 3.
• The risk of bleeding associated with aspirin use during surgery is a concern, and studies have shown that aspirin can increase the risk of bleeding and transfusion requirements 4, 5.
• On the other hand, some studies suggest that continuing aspirin therapy during the perioperative period may reduce the risk of thrombotic events, such as myocardial infarction and stroke 3, 5.

Specific Surgical Procedures

• For patients undergoing coronary artery bypass grafting surgery, the evidence suggests that aspirin may be continued until the day of surgery without increasing the risk of bleeding 3.
• However, for patients undergoing other types of surgery, such as non-cardiac surgery, the decision to withhold aspirin should be made on a case-by-case basis, taking into account the patient's individual risk factors and the potential benefits and risks of aspirin therapy 2.
• A systematic review and meta-analysis of randomized trials found that preoperative aspirin therapy reduced the risk of myocardial infarction, but increased the risk of bleeding and transfusion requirements in patients undergoing coronary artery surgery 5.

Long-Term Outcomes

• A study evaluating the 1-year outcomes of patients undergoing coronary artery surgery found that preoperative aspirin did not reduce death or severe disability, or thrombotic events through to 1 year after surgery 6.
• However, the study did not find any significant differences in the rates of myocardial infarction, stroke, or death between the aspirin and placebo groups 6.