Long time readers (and former patients) will be familiar with my aspirin mantra but now Medscape has published a CME course by Dr. Desiree Lie for health care providers in primary practice, general surgery (and other areas that may not be familiar with post-cardiac patient recommendations.) As I may have mentioned before, in cardiac surgery – we routinely start aspirin in our patients prior to bypass surgery.
Don’t stop Aspirin before surgery
I’ve converted the CME course, Don’t stop Aspirin before surgery into a pdf – but if you want credit – you will have to go to Medscape and log in. (For everyone else – it’s a nice read – and explains the importance of continuing aspirin in patients who are taking it for “secondary prevention” or are at high risk of cardiovascular events.
That’s because the complications of discontinuing aspirin therapy in these patients are WORSE than the minor risk of bleeding. (Bleeding issues for most patients taking aspirin are fairly minor.. Now, clopidogrel (Plavix) and prasugrel (Effient) are another story!)
Wait a second… What’s secondary prevention?
They way to think about secondary prevention is “closing the barn after the cows are loose,” as one of my colleagues explains it. This means that Aspirin has been prescribed to these patients after something has already happened – like a stroke, a heart attack, stents or cardiac surgery. So in these patients – secondary prevention can be thought of as preventing a second event or further complications from a disease process we already know about.
Now, patients that are at high risk for cardiovascular events like diabetics or people with other kinds of blockages (peripheral vascular disease, renal artery stenosis) haven’t had a heart attack yet – but we think that they are at a high risk of this happening – so they take aspirin to prevent this (primary prevention).
In people who are at low or moderate risk – low cholesterol, nonobese, normal glucose, nonsmokers: these people may take aspirin, but (probably not prescribed) and it is safe for them to discontinue aspirin before surgery.
But in the first two classes of patients (secondary prevention group/ high risk group) – stopping aspirin may actually INCREASE the risk of having a heart attack, stroke or other thrombotic event during surgery. But if you are having surgery – be sure to check with your cardiologist or cardiac surgeon before. Don’t rely on your PCP or general surgeon (it’s not their area of expertise) and they may not be up-to-date on the latest recommendations [hence the continuing education course].