Stopping Aspirin Before Coronary Artery Surgery

Abstract

Coronary artery bypass grafting (CABG) aims to reduce immediate and longer-term risks of myocardial infarction and death in patients with coronary artery disease. CABG is, however, associated with its own thrombotic risks of perioperative myocardial infarction, stroke, pulmonary embolism, and bowel infarction.1 These risks are of major concern to the patient and referring cardiologist. Although antiplatelet drugs such as aspirin and clopidogrel can reduce thrombotic events, they might add to a competing risk of excessive bleeding during and after surgery.2,3 Excessive bleeding leads to intraoperative and postoperative hypovolemia and hypotension, delayed completion of surgery, and higher rates of blood transfusion, postoperative tamponade, and reoperation for bleeding.3,–,6 The bleeding risks most often trouble the cardiac surgeon, and the traditional practice has been to stop aspirin before elective cardiac surgery. Article see p 577 How can we resolve the competing risks of bleeding complications (not uncommon, but sometimes serious and life threatening) versus thrombotic complications in the immediate preoperative and early postoperative period (far less common, but usually serious)? Is it true that efforts to minimize perioperative thrombotic risk will invariably increase bleeding complications? Cardiologists and surgeons have different perspectives and may weigh these issues differently, and it remains unclear as to how most CABG patients would perceive these risks and what their preferences may be. Cardiologists in particular will be familiar with this issue in the nonsurgical setting. The decision to commence anticoagulation for chronic atrial fibrillation must consider the likelihood of embolic stroke versus the possibility of serious bleeding complications, such as intracerebral hemorrhage.7 The latter situation is guided by numerous large-scale clinical trials. This is not the case in the CABG setting. Aspirin is associated with bleeding in both cardiac3,8,–,12 and noncardiac …