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Stopping vs. Continuing Aspirin before Coronary Artery Surgery

Sunday, February 28, 2016

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Source Name: New England Journal of Medicine


Paul S. Myles, Julian A. Smith, Andrew Forbes, Brendan Silbert, Mohandas Jayarajah, Thomas Painter, James Cooper, Silvana Marasco, John McNeil, Jean S. Bussières, Sophie Wallace

In this trial 2100 undergoing coronary surgery were randomized to aspirin 100mg or placebo. The primary outcome was defined as a composite of death and thrombotic complications (myocardial infarction, stroke, pulmonary embolism, renal failure or bowel infarction) at 30 days.

There was no difference between the two treatment groups for the primary endpoint (aspirin group 19.3% versus placebo group 20.4% , p=0.55). Other endpoints included cardiac tamponade (aspirin group 1.1% versus placebo 0.4%, p=0.08) and major hemorrhage leading to reoperation (aspirin group 1.8% versus placebo 2.1%, p=0.75).

The authors conclude that preoperative aspirin did not lead to a higher risk of death, thrombotic complications or reoperation due to bleeding.  


I like to know if there was also no difference in the group with left main stem disease and pre operative ACS. Also was there any difference in the rate of platelet transfusion in the group with or without aspirin.
I guess everybody will agree that aspirin will decrease the platelet function, and decreased platelet function will increase the risk of post-operative bleeding. Logistically, the risks of post-operative bleeding should be increased if we do not stop using aspirin before CABG. The differences might be significant if the sample size is larger.
I agree with Dr. Wei the risk of post-operative bleeding with aspirin increases and the problems in some hospitals when you ask for the products e.g platelates it is not available or it takes long time to be ready and this expose the patient for longer operative time and bleeding. We notice and encounter this problems as a surgeons in OR and in cardiac ICU. Still I can not understand the core rational for keeping the patient on aspirin preoperatively, some will say it avoid or reduce the events of chest pain and or MI but at the same time a large number of patient at home on DAPT ( Aspirin and thienopyridine e.g Plavix) and with all this protection still develop chest pain and MI . I feel we can stope aspirin in possible to avoid the agonizing intra/and post operative bleeding occurs to a large number of patient. Reading the article in New England Journal and you find that there is no difference between the 2 groups in the primary out comes and to me it can be understood both ways. I choose to stop aspirin days before surgery and start antithrombotics ( fractionated or unfractionated) and they can be stopped hours before going to OR to avoid the disturbing affect of non-surgical bleeding. I know a lot will not agree with this strategy but it works when you can not found the products when you need them.
Very nice study . It clarifies the position in the real life for coronary surgery prepartion.
Hii everyone, Practically im used to keep on Aspirine plus Antithrombotic (UFH or Enoxaparine) as long as dealing with Left Main,Diffuse critical disease,MI or ACS cases... To note that all CABGs cases im performing as OFFPump .. Noticing a very logical periop complications... So,selection in terms of disease morphology and operative technology will lead us to better decision of Aspirine preop use. Regards..
We need mor studies to know the high risk group of patients that mybe develop bleeding after sergury. Mybe mor sensivety for aspirin
I did not understand the rationale behind using 100mg of aspirin in the trial. Most of the times, the recommended anti-platelet dosage in IHD patients is either 81mg in the western population vis-a-vis 75-150mg in patients in the Indian subcontinent. Will the authors mind explaining?

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