What is the recommended management of aspirin therapy for a patient with uncontrolled epilepsy and a cardiovascular condition undergoing Coronary Artery Bypass Grafting (CABG) surgery?

Aspirin Management for CABG in Patients with Uncontrolled Epilepsy

Continue aspirin throughout the perioperative period at 81-100 mg daily, initiating within 6 hours postoperatively if not given preoperatively, and maintain indefinitely after CABG. 1

Preoperative Aspirin Management

Aspirin should be continued up to and including the day of surgery for patients undergoing CABG, as the cardiovascular benefits outweigh bleeding risks in this specific population. 1 The presence of uncontrolled epilepsy does not alter this recommendation, as aspirin does not significantly interact with antiepileptic medications or worsen seizure control.

Dosing Considerations

• Low-dose aspirin (81-100 mg daily) is the optimal preoperative dose for CABG patients, as it provides cardiovascular protection while minimizing bleeding complications. 1, 2, 3
• Higher doses (>100 mg/day) increase postoperative bleeding, packed red blood cell transfusion requirements, and reoperation rates without additional cardiovascular benefit. 4, 2
• Doses ≤100 mg/day do not significantly increase postoperative bleeding compared to placebo. 4

Evidence Supporting Continuation

• Preoperative aspirin reduces 30-day mortality by 27% in CABG patients. 2
• Perioperative myocardial infarction is reduced by 44% with preoperative aspirin, with low-dose aspirin showing even greater benefit (63% reduction). 2, 3
• Acute kidney injury incidence is reduced with preoperative aspirin at any dose. 3
• Aspirin significantly improves saphenous vein graft patency, particularly during the first postoperative year. 1

Postoperative Aspirin Management

If aspirin was not given preoperatively, initiate it within 6 hours postoperatively at 81-100 mg daily and continue indefinitely. 1 This timing is critical, as aspirin initiated beyond 48 hours after CABG loses its beneficial effect on graft patency. 1

Long-term Therapy

• Aspirin must be continued indefinitely after CABG to maintain graft patency and reduce cardiovascular events. 1
• The recommended maintenance dose is 81 mg daily (range 75-100 mg). 1
• Clopidogrel 75 mg daily is a reasonable alternative only in patients with true aspirin allergy or intolerance. 1

Special Considerations for Epilepsy

The uncontrolled epilepsy diagnosis does not contraindicate aspirin use for CABG, as:

• Aspirin does not lower seizure threshold or interact significantly with common antiepileptic drugs (phenytoin, carbamazepine, valproate, levetiracetam). 1
• The cardiovascular mortality risk from withholding aspirin far exceeds any theoretical bleeding risk from falls related to seizures. 1, 2
• If the patient experiences frequent tonic-clonic seizures with fall risk, ensure adequate seizure precautions are in place perioperatively, but do not discontinue aspirin. 1

Dual Antiplatelet Therapy Considerations

If the patient has had recent coronary stenting prior to CABG:

• Resume P2Y12 inhibitor (clopidogrel preferred) postoperatively to complete the recommended duration of dual antiplatelet therapy. 1
• For acute coronary syndrome patients, dual antiplatelet therapy should continue for 12 months total. 1
• Aspirin is continued throughout while the P2Y12 inhibitor is held 5 days preoperatively for clopidogrel or 3 days for ticagrelor. 1

Common Pitfalls to Avoid

• Never discontinue aspirin in the week before CABG based on outdated bleeding concerns—modern evidence strongly supports continuation. 1, 2, 3
• Do not use high-dose aspirin (>100 mg/day) preoperatively, as this increases bleeding without additional cardiovascular benefit. 4, 2
• Do not delay aspirin initiation beyond 48 hours postoperatively, as this eliminates the graft patency benefit. 1
• Do not substitute ticlopidine for aspirin due to its risk of life-threatening neutropenia and lack of superiority. 1
• Avoid combining aspirin with warfarin or dipyridamole for graft patency, as these add no benefit and increase bleeding risk. 1

Bleeding Risk Management

While preoperative aspirin increases postoperative bleeding volume (mean increase 132 mL), this does not translate to clinically significant harm when low-dose aspirin is used:

• Low-dose aspirin (≤100 mg/day) does not increase reoperation rates for bleeding. 4, 3
• Packed red blood cell transfusion requirements are not significantly increased with low-dose aspirin. 3
• The modest increase in bleeding is acceptable given the substantial reduction in mortality and myocardial infarction. 2, 3