Stopping vs. continuing aspirin before coronary artery surgery - Video Review

have you ever wondered if you should

discontinue aspirin in your patients who

are undergoing cabbage surgery well if

so then this paper will be right on the

study's title is stopping versus

continuing aspirin before coronary

artery surgery by miles at Al published

in the New England Journal of Medicine

in February 2016 here's what it's all

about let's start with some background

information it's been common practice in

many if not most cardiac centers to

discontinue aspirin five to seven days

before coronary artery bypass surgery or

cabbage in order to reduce the risk of

internal bleeding which would lead to

things like reoperation or cardiac

tamponade however as the risk of

bleeding goes down the risk of

thrombotic events might go up when

discontinuing aspirin so we might end up

with more cases of grafton boces

myocardial infarction or stroke now you

could say but aspirin is recommended

within 24 hours of surgery anyway in

order to prevent thrombotic events and

I'd say yes but this will not prevent

the patient from having very early

post-operative sombody complications

that's where the Atticus trial came into

the picture it was intended to answer

the question if aspirin would reduce the

occurrence of death and thrombotic

events in patients hort increased risk

of major complications undergoing

cabbage surgery patients were little if

they had not been taking aspirin

regularly before the trial or had

stopped taking aspirin at least four

days before cabbage surgery wulfrun and

clopidogrel had to be stopped at least

seven days before surgery the trial was

carried out between march two thousand

six in january 2013 overall 19 centers

in five countries participated 2,100

patients were included in the trial 1047

were randomized 100 milligrams of

aspirin in 1053 were randomized to

placebo patients doctors and Assessors

were all blinded to the actual treatment

given baseline characteristics like age

gender weight and comorbidities were all

similar in both groups that's important

in a randomized trial like this one so

we know that we're actually comparing

apples with apples and to see if

randomization was carried out


the mean age of participants was roughly

sixty six years and eighty-two percent

of them were males the study's primary

outcome was a composite of death and

thrombotic events that included

non-fatal myocardial infarction stroke

pulmonary embolism renal failure or

bowel infarction occurring during the

initial 30 post-operative days important

secondary outcomes included non-fatal

myocardial infarction occurring 30 days

postoperatively major bleeding leading

to reoperation and cardiac tamponade the

primary composite outcome occurred in

nineteen point three percent of patients

receiving aspirin and 20 point four

percent of patients receiving placebo

hazard ratio Oh point nine for

myocardial infarction occurred in

thirteen point eight percent of aspirin

patients and fifteen point eight percent

of placebo patients hazard ratio open

eight seven bleeding leading to

reoperation occurred in 1.8 versus 2.1

percent hazard ratio also open 87 in

cardiac tamponade occurred in 1.1

percent of aspirin patients versus open

four percent of placebo patients hazard

ratio 2.77 please note that all

confidence intervals cross the value of

1 which means that none of these hazard

ratios is statistically significant so

there's no difference between these

groups with respect to these outcomes

another important outcome length of stay

was seven days in both groups so also no

difference so what does that mean does

it mean that we shouldn't care about

continuing or withholding aspirin in

these patients the data seem to suggest

that both approaches seem to be okay or

maybe even equivalent we think that the

one key take-home message of this paper

is never change a winning team as simple

as that in other words you shouldn't

withdraw aspirin in these patients it's

safe in fact withdrawing aspirin might

lead to an increased risk of foreboding

events in the immediate preoperative

period in some instances surgery's

postponed and patients in whom aspirin

is not cancelled early enough which puts

a lot of burden on the patient and the

health care system and is really not

warranted apparently so again never

change a winning team that's what you

should take away from the Atticus trial

so I hope you enjoyed this video don't

forget to download the infographic that

comes with it and i'll talk to you soon