What are the recommendations for perioperative aspirin (acetylsalicylic acid) modification in a patient with uncontrolled epilepsy and a cardiovascular condition undergoing surgery?

Perioperative Aspirin Management

Direct Recommendation

In patients with cardiovascular disease undergoing noncardiac surgery, aspirin should generally be continued throughout the perioperative period unless the surgery involves a closed space (neurosurgery, intramedullary spine surgery) where even minor bleeding could cause catastrophic complications. 1

Decision Algorithm Based on Clinical Context

For Patients WITH Established Cardiovascular Disease

Continue aspirin perioperatively in the following scenarios:

• Patients with coronary stents (any type): Aspirin must be continued throughout the perioperative period regardless of stent type, as discontinuation markedly increases risk of catastrophic stent thrombosis, death, and myocardial infarction. 1, 2, 3

• Patients with coronary artery disease, prior stroke, or peripheral arterial disease: Continue aspirin when undergoing most noncardiac surgeries, as discontinuation increases absolute risk of stroke recurrence or cardiovascular events by approximately 2% within 30 days. 1, 2, 3

• Carotid endarterectomy: Aspirin continuation is specifically recommended for this procedure. 1, 3

• CABG surgery: Continue aspirin through the perioperative period, as it reduces myocardial infarction risk and improves vein graft patency. 3

Discontinue aspirin 5-10 days preoperatively in these high-risk bleeding scenarios:

• Neurosurgery and closed-space procedures: Stop aspirin 5-10 days before surgery where even minor bleeding can cause severe complications (intracranial surgery, intramedullary spine surgery). 3, 4

• Prostate surgery: Consider stopping aspirin due to elevated bleeding risk. 5

For Patients WITHOUT Established Cardiovascular Disease (Primary Prevention Only)

Discontinue aspirin perioperatively: For patients taking aspirin solely for primary prevention who are undergoing noncardiac surgery, aspirin should be discontinued and does not need to be restarted, as the POISE-2 trial demonstrated no cardiovascular benefit but increased bleeding risk. 2, 6

Timing of Discontinuation and Resumption

When aspirin must be stopped:

• Discontinue 5-7 days before surgery (not the traditional 7-10 days), as this allows adequate platelet regeneration while minimizing thrombotic risk. 3, 4

Postoperative resumption:

• Restart aspirin within 24 hours after surgery once adequate hemostasis is achieved. 2, 3
• For patients with coronary stents, restart aspirin immediately postoperatively and resume P2Y12 inhibitor as soon as possible. 1, 2

Special Considerations for Dual Antiplatelet Therapy (DAPT)

Patients with recent stent placement:

• Continue DAPT during urgent noncardiac surgery within the first 4-6 weeks after bare-metal stent or drug-eluting stent implantation, unless bleeding risk outweighs stent thrombosis prevention benefit. 1
• If P2Y12 inhibitor must be discontinued, continue aspirin and restart P2Y12 inhibitor as soon as possible postoperatively. 1
• Elective surgery should be delayed at least 30 days after bare-metal stent placement and ideally 12 months after drug-eluting stent placement. 3

Bleeding Risk Assessment

Quantifying the bleeding risk:

• Continuing aspirin increases the frequency of procedural bleeding by a relative risk of 1.5, but typically does not increase the severity of bleeding complications or perioperative mortality. 1, 3
• Major bleeding occurred in 4.6% of aspirin patients versus 3.8% of placebo patients in the POISE-2 trial. 6

Management decision framework:

• The decision to continue or discontinue aspirin should be determined by consensus of treating clinicians (surgeon, anesthesiologist, cardiologist) and the patient, weighing thrombotic risk against surgical bleeding risk. 1

Critical Caveats and Pitfalls

Common errors to avoid:

• Do not discontinue aspirin for longer than necessary (many clinicians stop for 10 days when 5-7 days is sufficient). 3
• Do not withhold aspirin indefinitely postoperatively in cardiovascular disease patients, as thrombotic events cluster early after discontinuation with highest risk in the first 30 days. 2
• Ensure thorough medication reconciliation to identify over-the-counter NSAIDs with antiplatelet effects that can impair aspirin's cardioprotective effects and increase bleeding risk. 2, 3
• Avoid combination therapy with multiple antiplatelet or anticoagulant medications immediately postoperatively without careful risk assessment, as bleeding risk increases significantly. 2

For patients with transfusion of platelets or prohaemostatic agents:

• In cases of excessive or life-threatening perioperative bleeding in patients on aspirin, platelet transfusion or administration of other prohaemostatic agents is recommended. 1

Epilepsy-Specific Considerations

The presence of uncontrolled epilepsy does not independently alter aspirin management recommendations. The decision remains based on cardiovascular risk versus surgical bleeding risk, following the algorithm above. However, ensure antiepileptic medications are continued perioperatively and verify no drug interactions exist between aspirin and the patient's antiepileptic regimen.