Niyogi SG, Batta A, Mohan B. Balancing bleeding, thrombosis and myocardial injury: A call for balance and precision medicine for aspirin in neurosurgery. World J Cardiol 2024; 16(12): 673-676 [DOI: 10.4330/wjc.v16.i12.673]
Corresponding Author of This Article
Akash Batta, DM, MD, Assistant Professor, Department of Cardiology, Dayanand Medical College and Hospital, Tagore Nagar, Civil Lines, Ludhiana 141001, Punjab, India. akashbatta02@gmail.com
Research Domain of This Article
Cardiac & Cardiovascular Systems
Article-Type of This Article
Editorial
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Cardiol. Dec 26, 2024; 16(12): 673-676 Published online Dec 26, 2024. doi: 10.4330/wjc.v16.i12.673
Balancing bleeding, thrombosis and myocardial injury: A call for balance and precision medicine for aspirin in neurosurgery
Subhrashis Guha Niyogi, Akash Batta, Bishav Mohan
Subhrashis Guha Niyogi, Department of Anesthesia, Tata Main Hospital, Jamshedpur 831001, Jharkhand, India
Akash Batta, Bishav Mohan, Department of Cardiology, Dayanand Medical College and Hospital, Ludhiana 141001, Punjab, India
Author contributions: Niyogi SG and Batta A designed the editorial; Niyogi SG performed the literature review and data collection; Mohan B and Batta A supervised the study and provided key feedback and suggestions; Niyogi SG and Batta A analysed the data and wrote the manuscript and subsequently revised it; and all authors have read and approved the final manuscript.
Conflict-of-interest statement: The authors declare that they have no conflict of interest to disclose.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Akash Batta, DM, MD, Assistant Professor, Department of Cardiology, Dayanand Medical College and Hospital, Tagore Nagar, Civil Lines, Ludhiana 141001, Punjab, India. akashbatta02@gmail.com
Received: May 27, 2024 Revised: October 4, 2024 Accepted: October 29, 2024 Published online: December 26, 2024 Processing time: 182 Days and 17.6 Hours
Abstract
Perioperative management of antiplatelet therapy involves a delicate balancing of the risk of periprocedural blood loss with the cardiovascular and thrombotic risk to the patient. Due to the unique nature of neurosurgery, perioperative bleeding may have devastating consequences and cause major morbidity and mortality. The recommendation to discontinue aspirin prior to major neurosurgical procedures rests upon conventional practice, expert consensus with priority given to avoidance of any major bleed. On the contrary recent prospective data do not support the existence of additional bleeding risk in patients continuing aspirin compared to those who stop aspirin prior to procedure. Patients with cardiovascular and metabolic comorbidities are increasingly encountered in the operation theatre these days. In these patients, prevention of myocardial injury after non-cardiac surgery (MINS) is an important focus for perioperative risk reduction. Prolonged (≥ 7 days) cessation of antiplatelets is one of the most important predictors of MINS. This complicated milieu of risks and benefits highlights the difficulty of practicing evidence-based medicine and minimizing harm in patients on aspirin needing neurosurgery.
Core Tip: The decision to continue or discontinue aspirin during the perioperative period is nuanced and must be tailored to each patient. The procedure-related bleeding risks of neurosurgery must be weighed against the potential patient-specific risks of thromboembolism, major adverse cardiac events as well as subclinical myocardial injury after non-cardiac surgery (MINS). MINS increases the risk of both early and late postoperative morbidity and mortality and can be triggered by prolonged (≥ 7 days) cessation of antiplatelets. Practice guidelines incorporating the latest evidence and point-of-care tests of platelet function are possible aids in this complicated scenario.
