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Should More Patients Continue Aspirin Therapy Perioperatively?: Clinical Impact of Aspirin Withdrawal Syndrome

Gerstein, Neal Stuart MD*; Schulman, Peter Mark MD; Gerstein, Wendy Hawks MD; Petersen, Timothy Randal PhD‡,*; Tawil, Isaac MD§

doi: 10.1097/SLA.0b013e318250504e
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Objective: To provide an evidence-based focused review of aspirin use in the perioperative period along with an in-depth discussion of the considerations and risks associated with its preoperative withdrawal.

Background: For patients with established cardiovascular disease, taking aspirin is considered a critical therapy. 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, which are exacerbated during the perioperative period, standard practice has been to stop aspirin before elective surgery for fear of excessive bleeding. Mounting evidence suggests that this practice should be abandoned.

Methods: We performed a PubMed and Medline literature search using the keywords aspirin, withdrawal, and perioperative. We manually reviewed relevant citations for inclusion.

Results/Conclusions: Clinicians should employ a patient-specific strategy for perioperative aspirin management that weighs the risks of stopping aspirin with those associated with its continuation. Most patients, especially those taking aspirin for secondary cardiovascular prevention, should have their aspirin continued throughout the perioperative period. When aspirin is held preoperatively, the aspirin withdrawal syndrome may significantly increase the risk of a major thromboembolic complication. For many operative procedures, the risk of perioperative bleeding while continuing aspirin is minimal, as compared with the concomitant thromboembolic risks associated with aspirin withdrawal. Those cases where aspirin should be stopped include patients undergoing intracranial, middle ear, posterior eye, intramedullary spine, and possibly transurethral prostatectomy surgery.

For patients with cardiovascular disease (CVD) or major CVD risk factors, taking aspirin is a critical therapy that should be continued indefinitely. Aspirin cessation can cause a platelet rebound phenomenon and a prothrombotic state leading to major adverse cardiovascular events in the perioperative period. For the majority of operative procedures, the risk of bleeding while continuing aspirin are minimal versus the concomitant thromboembolic risks associated with its withdrawal.

*Department of Anesthesiology and Critical Care Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico

Department of Internal Medicine, New Mexico Veterans Affairs Health Care System

Department of Anthropology, University of New Mexico, Albuquerque, New Mexico

§Departments of Surgery and Emergency Medicine, University of New Mexico School of Medicine

Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, Oregon.

Reprints: Neal Stuart Gerstein, MD, Department of Anesthesiology and Critical Care Medicine, University of New Mexico School of Medicine, MSC 10-6000, 1 University of New Mexico, Albuquerque, NM 87131. E-mail: ngerstein@gmail.com.

Disclosure: The authors declare no conflicts of interest.

© 2012 Lippincott Williams & Wilkins, Inc.