When to start aspirin after surgery
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
appropriate
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
