HEALTH MATTERS: Blood thinners before surgery
Q. I am scheduled for surgery next week and I’m taking a daily baby aspirin because I also have a coronary artery blockage. Should I stop the aspirin to reduce my risk of bleeding or continue it to reduce my risk of having a heart attack?
A. Yes, you should do both.
Aspirin has two effects — by inhibiting platelets, which are small cells that circulate in the blood, aspirin reduces the chance of those platelets sticking together and totally blocking a heart artery, thus producing a heart attack. On the other hand, by making it harder for the platelets to stick together, aspirin increases the risk of bleeding at the time of surgery.
A just-published study of more than 10,000 patients undergoing noncardiac surgery showed no major benefit of using aspirin around the time of surgery (that is, no lowered risk of heart attack or death), and a moderately increased risk of major bleeding.
So what would I recommend? Based on this latest study and my experience in taking care of patients like you, I’d probably stop the aspirin around three days before surgery and restart it as soon after as your surgeon feels it is safe to do so. Although, in some patients who are at higher cardiac risk, I’d continue the aspirin during surgery despite the increased risk of bleeding.
And it is important to emphasize two caveats — these recommendations only apply to noncardiac surgery because we routinely use aspirin in patients undergoing heart bypass surgery, and these recommendations do not apply to patients who have had a stent inserted in a heart artery. In those patients, we try to continue the aspirin during and after surgery, especially if the stent insertion was recent. Above all, it is imperative for patients to discuss aspirin use around the time of surgery with their primary care provider and surgeon — so please have that conversation soon.
Q. I understand there has been a change in the recommendations regarding the management of high blood pressure.
A. You are correct; the most noteworthy change was the decision to relax the target blood pressure for people without diabetes or kidney disease — and who are 60 or older — from 140 to 150 systolic (the top number when we talk about blood pressure). This is because there isn’t good data from clinical trials that studied large numbers of people with high blood pressure to determine the optimal level, and as you might guess, not all experts agree with this change.
Some feel our target for this group should remain at less than 140 systolic. So, you need to discuss the correct target for you with your health care provider. But almost all experts agree there is strong evidence to support treating blood pressure levels above 150 in nearly all people, with a target level of no higher than 140 for those younger than 60, those older than 60 with diabetes, and those younger than 70 with kidney disease. And virtually all of us would be particularly cautious about overly aggressive blood pressure management in the truly elderly (older than 80) — such treatment can lead to serious complications.
Wynne is vice president for health affairs at UND, dean of the School of Medicine and Health Sciences, and a professor of medicine. He is a cardiologist by training.
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