NEW YORK (Reuters Health) – For patients undergoing coronary artery bypass surgery, discontinuing chronic aspirin therapy at least 6 days before or within 5 days of surgery has no effect on postop cardiovascular outcomes. However, early discontinuation is associated with less need for transfusions, according to a report from the Cleveland Clinic, Ohio.

While aspirin before and after CABG reduces adverse postop outcomes, it is discontinued perioperatively because of concerns about bleeding complications, Dr. Leslie Cho and colleagues explain in the February 15 issue of Circulation. The optimal timing for stopping aspirin is controversial, however.

The investigators therefore analyzed their institution’s data on 4143 CABG patients who were on chronic aspirin therapy preoperatively; 2298 discontinued aspirin 6 or more days before surgery (early discontinuation) while1845 were on aspirin within 5 days of the surgery (late use).

Propensity scores and 31 variables were used to match 1519 patients from each group.

“There was no significant difference between those with early discontinuation and late ASA use with regard to the composite outcome of in-hospital mortality, myocardial infarction, and stroke (1.7% versus 1.8%, p=0.80),” the authors report.

However, 23% of patients in the late-use group required intraoperative transfusions compared with 20% (p=0.03) in the early-discontinuation group. Corresponding rates for postoperative transfusions were 30% vs 26% (p=0.009)

On the other hand, there was not a significant difference in the need for reoperation because of bleeding (3.4% vs 2.4%; p=0.10).

“On the basis of the present study,” Dr. Cho and colleagues conclude, “we recommend that clinicians weigh the risks and benefits of late ASA use on the basis of the patient’s risk profile before CABG.”

An editorialist wonders if aspirin need be stopped at all before coronary artery surgery. Or perhaps antifibrinolytic therapy can offset bleeding tendencies with aspirin without affecting its antithrombotic benefit.

These possibilities are being examined in the ongoing ATACAS trial, notes Dr. Paul S. Myles of Alfred Hospital in Melbourne, Victoria, Australia.

“If aspirin used on the day of CABG leads to a reduction in thrombotic complications, without major bleeding complications,” he writes, “then there will be no need to stop aspirin before elective CABG.”

Reference:

Stopping Aspirin Before Coronary Artery Surgery: Between the Devil and the Deep Blue Sea

Circulation 2011;123:571-573,577-583.