Stopping aspirin before CABG: Timing depends on bleeding, thrombosis risk

Posted by: admin on: May 19, 2011

It makes little difference to the risk of MI, stroke, or death whether chronic aspirin therapy is discontinued earlier than five days or within five days of CABG surgery


Withdrawal of aspirin within five days of surgery in the analysis was associated with greater need for peri and postoperative transfusion. Later aspirin withdrawal doesn’t necessarily always tip the balance of risk in favor of stopping aspirin earlier, as that could leave some patients at increased risk of preoperative cardiac events

The need is for weighing benefit vs risk in individual patients when deciding how long before CABG to suspend chronic aspirin therapy.

So the important thing would be for physicians to assess patients, to weigh the risks and benefits, in terms of bleeding and ischemic end points, from discontinuing aspirin in certain patient populations. For example, if patients are at high risk of bleeding because they’re elderly, they’re small, or they’re female, then perhaps for those patients it would be better to go off aspirin longer than five days [before surgery].

But those with drug-eluting stents should perhaps stay on aspirin longer and for those patients, we have to unfortunately accept the bleeding risk, because having stent thrombosis prior to bypass surgery leads to such a detrimental outcome.

The current study “provides some reassurance as to the comparable postoperative cardiovascular complications after CABG for both early and late discontinuation of aspirin.” But a bigger question is “whether or not we should be stopping aspirin at all.”

The composite rate of in-hospital death, MI, or stroke was about the same for patients who went off aspirin earlier and those who went off it later. And the rates of the composite end point’s individual components were not significantly different. But the risk of bleeding during and after the procedure went up with later aspirin withdrawal. Postoperative length of stay was similar, a median of six days for both groups.

Clinical event and bleeding complication rates for 1519 matched pairs by timing of chronic aspirin withdrawal before CABG

End point Aspirin withdrawal >6 d before CABG (%) Aspirin withdrawal <5 d before CABG (%) p
In-hospital death, MI, or stroke (primary outcome) 1.7 1.8 0.80
Intraoperative transfusion 20 23 0.03
Postoperative transfusion 26 30 0.009

Withdrawal of aspirin within five days of surgery in the analysis was associated with greater need for peri- and postoperative transfusion. As post-operative complication goes up, probably so would the risk of bleeding, and there are data to support that from populations with ST-elevation MI and other ACS.


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