Dr K K Aggarwal

Do not stop aspirin

According to the current study by Gerstein and colleagues, more than 50 million adults in the United States take aspirin regularly for primary and secondary prevention of cardiovascular disease. The cessation of aspirin can cause a platelet rebound phenomenon and prothrombotic state leading to major adverse cardiovascular events. Despite the risks of aspirin withdrawal, exacerbated during the perioperative period, standard practice has been to stop aspirin before elective surgery for fear of excessive bleeding, but evidence suggests that this practice should be abandoned.

The evidence found in a PubMed and Medline literature search “strongly supports” continued perioperative use of aspirin in patients taking it for secondary prevention of coronary artery disease, cerebrovascular disease, and peripheral vascular disease.

“Routine discontinuation of aspirin seven to 10 days preoperatively is not only unjustified but likely significantly compounds patients’ thromboembolic risk because of the described aspirin withdrawal syndrome that occurs contemporaneously during this time interval,” said Dr. Neal Stuart Gerstein from University of New Mexico in Albuquerque and colleagues.

“For an at-risk patient, the hypercoagulable state engendered by the surgical procedure compounded by the aspirin withdrawal syndrome creates an ideal scenario for a major cardiac or vascular thromboembolic complication,” they write in Annals of Surgery for May.

Surgical procedures that involve particular anatomic locations, including middle ear, posterior chamber of the eye, intracranial, intramedullary spine and possibly transurethral prostatectomy (TURP) confer the highest risk of complicating hemorrhage while on aspirin therapy.

The thromboembolic risks of aspirin cessation in the at-risk patient often outweigh the minor bleeding risks in the vast majority of operative procedures.

The POISE-2 trial, promises to shed light on this issue. POISE-2 is a 10,000-patient randomized controlled trial that is evaluating the impact of perioperative ASA in patients undergoing noncardiac surgery. In this trial, half the patients are taking chronic ASA and they have to stop it at least three days before surgery, and then they are randomized to restart low-dose ASA or placebo just prior to surgery and they continue it until day eight after surgery when they resume their normal ASA. The other half of the patients in POISE-2 are patients who do not take chronic ASA and they are randomized to start low-dose ASA or placebo just prior to surgery and they take the study drug daily until day 31 after surgery.