The role of antiplatelet therapy in acute coronary syndromes and for secondary prevention following a myocardial infarction

The Impact of Aspirin in Brain Tumor Surgery: To Stop or Not to Stop?

Given the lack of guidelines regarding perioperative management of neurosurgical patients taking antiplatelet medication, a break of aspirin intake for elective brain surgery is recommended. To the best of our knowledge, only three clinical studies have been published comparing re-bleeding rates in patients undergoing elective brain surgery with and without aspirin. We present a case of an 81-year-old woman who was admitted for elective craniotomy and brain metastases resection. She presented with a right-sided hemianopsia for > two weeks and further investigation by magnetic resonance imaging (MRI) showed the left occipital lesion. For primary cardiovascular prevention, the patient was prescribed prophylactic low-dose aspirin 100 mg. A platelet function test on the day of admission detected highly pathological values. Surgery was scheduled the next day, and aspirin intake was paused. The platelet function test was repeated the morning before surgery. Interestingly, the test showed a 20% above-normal level platelet function. Craniotomy and tumor resection were performed in a routine fashion and no increased bleeding tendency was reported intraoperatively. Postoperatively, the right-sided hemianopsia was immediately regressive. MRI performed 24 hours after surgery demonstrated a complete tumor resection without any signs of rebleeding. The patient was discharged five days after surgery without any neurological deficits. The literature is limited and guidelines are missing on the topic of management of antiplatelet medication in elective brain surgery. As confirmed by the present case and a review of the literature, elective craniotomy and tumor resection under antiplatelet medication may be considered in certain cases with risk and benefit stratification. More data and randomized controlled trials are needed to confirm these findings.

Influence of aspirin on post-extraction bleeding - A clinical study

Aim:

The aim of the study was to evaluate the influence of aspirin on post-extraction bleeding in a clinical setup.

Materials and Methods:

Two hundred patients aged between 50 and 65 years who were indicated for dental extraction for endodontic reason were selected from the outpatient Department of Oral and Maxillofacial Surgery. The patients were randomly divided into aspirin continuing group (group A) and aspirin discontinuing group (group B). After checking all the vital signs, the extractions were carried out. Bleeding time and clotting time were recorded for evaluation by Chi-square test.

Results:

Chi-square test revealed that the bleeding time increased (3.8 ± 0.75) in group A patients continued with the aspirin therapy where as group B discontinued aspirin. Similarly, the clotting time increased in group B patients and decreased in group A patients. But in both the groups, bleeding and clotting time remained within normal limits.

Conclusion:

Reviewing most of the dental and medical literature, it can be concluded that there is absolutely no need to discontinue antiplatelet therapy for any ambulatory dental procedure, and even if the practitioner wishes to discontinue, it should not be for more than 3 daAQ2ys. This is also stated in the guidelines of the American Heart Association.

Dental extraction can be performed safely in patients on aspirin therapy: a timely reminder

Cardiac patients on aspirin therapy may require extractions for their diseased teeth. It is a common practice among physicians and treating surgeons to stop aspirin prior to tooth extraction because of fear of bleeding complications. This practice often predisposes the patient to adverse thromboembolic events. This practice is based on theoretical risk of bleeding and on isolated case reports of excessive bleeding with aspirin therapy. The current consensus and recommendations are in favor of continuing aspirin therapy during simple tooth extraction as the bleeding complication incidence is very less and if it occurs can be controlled efficiently with local hemostasis measures.

Management of a dentigerous cyst in a medically compromised geriatric patient: a case report

BACKGROUND

Because of the increasing number of older persons seeking dental care, the growing trend towards a longer dental appointment and increased administration of drugs in dentistry, the possibility of occurrence of medical emergencies in dental offices has shown an upward trend.

OBJECTIVE

This case report discusses enucleation of a central dentigerous cyst in a 72-year old male on long-term low dose aspirin therapy.

MATERIAL AND METHODS

Surgical removal of impacted tooth with total enucleation of cystic lesion was performed in the dental chair under 2% lidocaine with 1:200,000 adrenaline, 3 days after aspirin cessation. After complete debridement of the surgical site, the wound was sutured and a gauge saturated with 10% tranexamic acid was placed on surgical site for 30 minutes.

RESULT

No post-operative complications or bleeding was seen on subsequent appointment and healing was normal.

CONCLUSION

A geriatric and medically compromised patient demands special care and attention; and the decision to cease aspirin before surgery or not is of critical importance.

Minor Oral Surgery Without Stopping Daily Low-Dose Aspirin Therapy: A Study of 51 Patients

PURPOSE

The risk of excessive bleeding prompts physicians to stop low-dose long-term aspirin regimens before surgery, which puts the patient at risk from adverse thrombotic events. We hypothesize that most minor oral surgical procedures can be carried out safely without stopping low-dose aspirin.

PATIENTS AND METHODS

All minor oral surgery patients at our hospital (Madan Dental Hospital, Ahmedabad, India) from May 2002 to May 2003, who were also on long-term low-dose aspirin therapy regimens (acetylsalicylic acid 75 mg to 100 mg/day), were included. Investigation of bleeding time and platelet count was performed. If within normal limits, aspirin was not stopped before surgery. Patients were operated under local anesthesia on an outpatient basis. All wounds were sutured and followed up at 24, 48, and 72 hours, 1 week, and 2 weeks after the procedure.

RESULTS

The study included 51 patients (32 males, 19 females), ranging in age from 45 to 70 years. Preoperative values were within normal limits for all patients. Aspirin was not stopped for a single patient. There was no excessive intraoperative bleeding in all cases except 1; there was no postoperative bleeding in all cases.

CONCLUSION

We conclude that most minor oral surgery procedures can be carried out safely without stopping long-term low-dose aspirin regimen.

Does low-dose aspirin therapy complicate oral surgical procedures?

BACKGROUND

The fear of uncontrolled bleeding often prompts medical practitioners to stop aspirin intake for seven to 10 days before any surgical procedure. The authors initiated this study to evaluate the effect of aspirin on bleeding in patients undergoing oral surgery.

METHODS

The study group consisted of 39 patients who were scheduled to undergo dental extractions. All patients were receiving 100 milligrams of aspirin daily on a regular basis. The authors randomly divided the patients into two groups: those who stopped the aspirin therapy before the procedure and those who continued the aspirin therapy. One hour before the procedures, all patients underwent a bleeding time test. In addition, the amount of bleeding during the procedure was measured.

RESULTS

The mean (+/- standard deviation) bleeding time was 1.8 +/- 0.47 minutes for patients who stopped aspirin therapy one week before the procedure. For patients who continued aspirin therapy, the bleeding time was 3.1 +/- 0.65 minutes. The difference was statistically significant (P = .004). However, both groups were within the normal bleeding time range, and in both groups, a local hemostatic method was sufficient to control bleeding. No episodes of uncontrolled intraoperative or postoperative bleeding were noted.

CONCLUSION

Low-dose aspirin therapy should not be stopped before oral surgery. Local hemostasis is sufficient to control bleeding.

CLINICAL IMPLICATIONS

Patients receiving aspirin therapy to prevent blood clot formation may be subject to emboli formation if the treatment is stopped. The results of this study show that aspirin therapy should be continued throughout oral surgical procedures. Local measures are sufficient to control any bleeding during surgery.

Effects of aspirin and trapidil on cardiovascular events after acute myocardial infarction. Japanese Antiplatelets Myocardial Infarction Study (JAMIS) Investigators

Aspirin therapy confers conclusive net benefits in the acute phase of evolving myocardial infarction, but no clear evidence of benefit from the long-term use of aspirin after acute myocardial infarction (AMI) has been shown in any single study. This multicenter study, the Japanese Antiplatelets Myocardial Infarction Study, was performed to find out whether aspirin or trapidil would improve clinical outcome compared with no antiplatelets in postinfarction patients. The study was a multicenter, open-label, randomized controlled trial of aspirin 81 mg/day, trapidil 300 mg/day, and no antiplatelets in patients with AMI admitted within 1 month from the onset of symptoms. Seven hundred twenty-three patients were enrolled at 70 hospitals in 18 prefectures of Japan; 250 were randomly assigned to treatment with 81 mg aspirin (aspirin group), 243 to that with trapidil (trapidil group), and 230 were not given antiplatelet agents. The mean follow-up period was 475 days. This study demonstrated that long-term use of aspirin at the dose of 81 mg/day reduced the incidence of recurrent AMI compared with the group receiving no antiplatelets after AMI (p = 0.0045) and that trapidil also reduced the occurrence of reinfarction compared with the group receiving no antiplatelets, but the difference was not significant (p = 0.0810). The incidence of cardiovascular events including cardiovascular death, reinfarction, uncontrolled unstable angina requiring admission to hospital, and nonfatal ischemic stroke was reduced in the group receiving 300 mg trapidil daily compared with the group receiving no antiplatelets (p = 0.0039). The use of aspirin 81 mg/day provided almost no benefit over no antiplatelets therapy in the incidence of cardiovascular events. In conclusion, low-dose aspirin (81 mg) effectively prevented recurrent AMI in postinfarction patients after thrombolysis or coronary angioplasty when used over a long term. Furthermore, the long-term use of trapidil resulted in a significant reduction in the incidence of cardiovascular events.

Management of myocardial infarction patients with an occluded infarct-related artery

Based on the foregoing data it is not unreasonable to hypothesize that restoration of flow in the infarct-related artery at a later date might decrease mortality. If that is the case, then a strong argument can be made for coronary angiography in patients surviving acute myocardial infarction. Of course, the ideal way to investigate this problem is to perform a large-scale prospective trial in which patients who have an occluded infarct-related artery are randomized to a revascularization procedure or continued on nonsurgical therapy. The specific management strategy for the patient with an occluded infarct-related artery after myocardial infarction depends on several features that the patient exhibits. For example, the presence or absence of LV dilatation, arrhythmias, recurrent ischemia, or clinical heart failure may dictate one form of therapy or another. There is no generic postinfarction patient with an infarct-related artery occlusion. Choices of drugs to use in these patients include the vasodilators, such as nitrates and ACE inhibitors, as well as aspirin and beta blockers. The use of calcium antagonists, chronic anticoagulants, and antiarrhythmics should have specific indications. Antithrombin agents are still experimental.