From the Guidelines
Aspirin should not be withheld for procedures in patients taking low-dose aspirin (81-100 mg daily) for cardiovascular protection, as the risk of thrombotic events may outweigh the risk of bleeding 1.
Key Considerations
- The decision to hold aspirin should be individualized based on the patient's specific clinical circumstances and the type of procedure being performed 1.
- For patients taking higher doses of aspirin (325 mg or more daily) or combination therapy with other antiplatelet agents, such as clopidogrel or prasugrel, it is recommended to hold the medication 5-7 days prior to the procedure to minimize bleeding risk 1.
- Bleeding Risk vs. Thrombotic Events: the risk of cardiac events outweighs the risk of bleeding in patients with CAD without prior PCI undergoing elective NCS, and it may be reasonable to continue aspirin in selected patients 1.
- Procedure-Specific Considerations: for procedures with a high risk of bleeding, such as neurosurgery, it is proposed that invasive procedures should be performed only after five days of aspirin washout 1.
Management of Aspirin Therapy
- Aspirin inhibits the synthesis of thromboxane A2 irreversibly, and the time required for the full recovery of thromboxane A2 synthesis is that of the total turnover of circulating platelets, which is normally about 10 days but may in some circumstances be shorter 1.
- A three-day washout of aspirin leads to an improvement in platelet functions that is often but not always sufficient for full correction of platelet functions 1.
From the Research
Aspirin Withdrawal for Procedures
- The decision to withhold acetylsalicylic acid (ASA) (aspirin) for procedures is complex and depends on various factors, including the type of procedure, patient's cardiovascular risk, and bleeding risk 2, 3, 4, 5, 6.
- Studies have shown that continuing aspirin through noncardiac surgery can reduce the risk of major adverse cardiac events (MACE) but may lead to higher bleeding complications 2, 3, 6.
- However, other studies have found that the risk of bleeding complications is not significantly increased with continued aspirin use, and that the benefits of continued aspirin use may outweigh the risks in patients with higher cardiovascular risk 2, 4, 6.
Bleeding Risks and Aspirin Continuation
- A study found that aspirin increased the rate of bleeding complications by a factor of 1.5, but did not lead to a higher level of severity of bleeding complications, except in cases of intracranial surgery and possibly transurethral prostatectomy 3.
- Another study found that percutaneous nephrolithotomy appears to be effective and safe in patients who continue low-dose aspirin perioperatively, with no significant difference in bleeding complications or transfusion rates 4.
- A study also found that 660 mg of aspirin can effectively shorten the bleeding time prolonged by daily low-dose (81 mg) aspirin, potentially reducing the risk of bleeding complications 5.
Cardiovascular Risks and Aspirin Discontinuation
- Aspirin withdrawal has been shown to precede up to 10.2% of acute cardiovascular syndromes, with a time interval between discontinuation and acute cerebral events of 14.3 +/- 11.3 days 3.
- A study found that discontinuation of aspirin may increase the risk of cardiac complications, with a trend towards an increased risk of cardiac complications in patients who discontinued aspirin 6.
- Another study found that continuation of aspirin may be associated with a favorable perioperative cardiac outcome, with no significant difference in the risk of relevant perioperative bleeding complications 6.