Burger W, Chemnitius J-M, Kneissl G D, Rücker G
Department of Interventional Cardiology, St Georg Hospital, Leipzig, Germany.
J Intern Med. 2005 May;257(5):399-414. doi: 10.1111/j.1365-2796.2005.01477.x.
Low-dose aspirin given for secondary prevention of cardiovascular disease is frequently withdrawn prior to surgical or diagnostic procedures to reduce bleeding complications. This may expose patients to increased cardiovascular morbidity and mortality. Aim of the study was to review and quantify cardiovascular risks because of periprocedural aspirin withdrawal and bleeding risks with the continuation of aspirin.
We screened MEDLINE (January 1970-October 2004) with additional manual cross-referencing for clinical studies, surveys on the opinions of doctors and guidelines.
Studies reporting the relative risk of acute cardiovascular events after aspirin withdrawal when compared with its continuation were not found. However, retrospective investigations revealed that aspirin withdrawal precedes up to 10.2% of acute cardiovascular syndromes. The time interval between discontinuation and acute cerebral events was 14.3 +/- 11.3 days, 8.5 +/- 3.6 days for acute coronary syndromes, and 25.8 +/- 18.1 days for acute peripheral arterial syndromes (P < 0.02 versus acute coronary syndromes). On aspirin-related bleeding risks, we obtained 41 (12 observational retrospective, 19 observational prospective, 10 randomized) studies, reporting on 49 590 patients (14 981 on aspirin). Baseline frequency of bleeding complications varied between 0 (skin lesion excision, cataract surgery) and 75% (transrectal prostate biopsy). Whilst aspirin increased the rate of bleeding complications by factor 1.5 (median, interquartile range: 1.0-2.5), it did not lead to a higher level of the severity of bleeding complications (exception: intracranial surgery, and possibly transurethral prostatectomy). Surveys amongst doctors on the management of this problem demonstrate wide variations. Available guidelines are scarce and in part contradictory.
Only if low-dose aspirin may cause bleeding risks with increased mortality or sequels comparable with the observed cardiovascular risks after aspirin withdrawal, it should be discontinued prior to an intended operation or procedure. Controlled clinical studies are urgently needed.
用于心血管疾病二级预防的低剂量阿司匹林，常在外科手术或诊断性操作前停用，以减少出血并发症。这可能会使患者心血管发病率和死亡率增加。本研究的目的是回顾并量化围手术期停用阿司匹林带来的心血管风险以及继续使用阿司匹林时的出血风险。
我们检索了MEDLINE（1970年1月至2004年10月），并辅以人工交叉引用，查找临床研究、医生意见调查及指南。
未找到报告停用阿司匹林与其继续使用相比急性心血管事件相对风险的研究。然而，回顾性调查显示，高达10.2%的急性心血管综合征发生在阿司匹林停用之前。停用与急性脑事件之间的时间间隔为14.3±11.3天，急性冠状动脉综合征为8.5±3.6天，急性外周动脉综合征为25.8±18.1天（与急性冠状动脉综合征相比，P<0.02）。关于阿司匹林相关的出血风险，我们获得了41项（12项观察性回顾研究、19项观察性前瞻性研究、10项随机研究）研究，涉及49590例患者（14981例使用阿司匹林）。出血并发症的基线发生率在0（皮肤病变切除、白内障手术）至75%（经直肠前列腺活检）之间变化。虽然阿司匹林使出血并发症发生率增加了1.5倍（中位数，四分位间距：1.0 - 2.5），但并未导致出血并发症严重程度升高（颅内手术及可能的经尿道前列腺切除术除外）。医生关于该问题处理的调查显示差异很大。可用的指南很少且部分相互矛盾。
仅当低剂量阿司匹林可能导致出血风险增加，且死亡率或后遗症与停用阿司匹林后观察到的心血管风险相当时，才应在预定手术或操作前停用。迫切需要进行对照临床研究。
