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Aspirin Discontinuation Perioperatively Increases Cardiovascular Events
Samuel Z. Goldhaber, M.D.
Review: Burger W, Chemnitius JM, Kneissl GD, Rücker G. Low-dose aspirin for secondary cardiovascular prevention - cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation - review and meta-analysis. J Intern Med. 2005 May;257(5):399-414.
The authors raise the question of optimal management of low-dose aspirin at the time of surgery. Should it be withdrawn one week in advance of an operation or should it be continued? The authors claim that low-dose aspirin is frequently withdrawn. In my experience, aspirin is withdrawn when laparoscopic colonic polypectomy or percutaneous organ biopsy is planned electively. Otherwise, aspirin is continued perioperatively, especially for cardiac surgical or peripheral vascular operations in which the baseline risk of myocardial infarction is increased due to underlying cardiovascular morbidity.
Nevertheless, these German investigators were sufficiently concerned about this problem that they undertook an ambitious meta-analysis. This project must have taken a great deal of time to complete. Pouring through the source material must have been painstaking and at times boring and monotonous. However, the final product was worth the effort. Their paper contains 1 table, 5 figures, and 74 references, so it's a good starting point for reviewing key studies of low-dose aspirin. Not surprisingly, they find that aspirin withdrawal leads to more strokes, more episodes of acute coronary syndrome, and more frequent peripheral vascular ischemia.
I certainly wouldn't change my practice one bit after reading this paper. My interpretation is that my current recommendation of continuing aspirin prior to major surgery (except perhaps neurosurgery) is right on target.
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