Perioperative management of patient on aspirin: Current view.

Sir,

We read with interest the article published in J Anaesthesiol Clin Pharmacol 2016;32:103-5. Bhargava et al. reported a case of an elderly man with double vessel disease, poor left ventricular function, and concomitant anomalous origin of the left anterior descending artery from the right coronary artery for repair of irreducible obstructed paraumbilical hernia.[1] However, it raises certain issues.

The authors had stopped aspirin preoperatively for their patient. When aspirin is held preoperatively, the aspirin withdrawal syndrome may significantly increase the risk of a major thromboembolic complication. This causes concerns particularly in the present scenario, where the patient in reference had poor left ventricular function (left ventricular ejection fraction 25%). 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. We recommend that aspirin be continued perioperatively, however exceptions include intracranial, middle ear, posterior eye, intramedullary spine, and possibly transurethral prostatectomy surgery.[23]

Aspirin is the most commonly used antiplatelet agent in the primary and secondary prevention of cardiovascular events. Aspirin withdrawal is associated with a “rebound” phenomenon that is prothrombotic and/or proinflammatory that plays a causative role in adverse events. This rebound hypothesis, as a scientific entity, can be defined as an increase in platelet reactivity following aspirin withdrawal, to a level exceeding that at baseline before initiation of aspirin therapy.[4] This rebound period is characterized by increased thromboxane production, decreased fibrinolysis, and a resultant clinical prothrombotic state. Platelet function rebound is dose dependent, with a more rapid rebound associated with withdrawal of lower aspirin doses.[3] In patients on antiplatelet therapy undergoing surgery, bridging antiplatelet therapy is started if warranted in the given situation instead of anticoagulants.[5]

Discontinuation of aspirin preoperatively significantly compounds patient's thromboembolic risk because of rebound hypercoagulability. For an at-risk patient, the hypercoagulable state aggravated by the surgical procedure and further compounded by the aspirin withdrawal creates an ideal scenario for a major cardiac or vascular thromboembolic complication. Based on the current evidence, anesthesiologists should continue the perioperative use of aspirin for the beneficial effects on cardiovascular outcomes.

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