A Comprehensive Update on Aspirin Management During Noncardiac Surgery

Neal S. Gerstein, MD, FASE; Cory L. Albrechtsen, BS; Nestor Mercado, MD, PhD; Joaquin E. Cigarroa, MD; Peter M. Schulman, MD

Disclosures

Anesth Analg. 2020;131(4):1111-1123. 

In This Article

Abstract and Introduction

Abstract

Aspirin is considered critical lifelong therapy for patients with established cardiovascular (CV) disease (including coronary artery, cerebrovascular, and peripheral arterial diseases) and is consequently one of the most widely used medications worldwide. However, the indications for aspirin use continue to evolve and recent trials question its efficacy for primary prevention. Although one third of patients undergoing noncardiac surgery and at risk for a major adverse CV event receive aspirin perioperatively, uncertainty still exists about how aspirin should be optimally managed in this context, and significant practice variability remains. Recent trials suggest that the risks of continuing aspirin during the perioperative period outweigh the benefits in many cases, but data on patients with high CV risk remain limited. We performed a comprehensive PubMed and Medline literature search using the following keywords: aspirin, aspirin withdrawal, perioperative, coronary artery disease, cerebrovascular disease, peripheral artery disease, and CV disease; we manually reviewed all relevant citations for inclusion. Patients taking aspirin for the primary prevention of CV disease should likely discontinue it during the perioperative period, especially when there is a high risk of bleeding. Patients with established CV disease but without a coronary stent should likely continue aspirin during the perioperative period unless undergoing closed-space surgery. Patients with a history of coronary stenting also likely need aspirin continuation throughout the perioperative period for nonclosed space procedures. Perioperative clinicians need to balance the risks of ceasing aspirin before surgery against its continuation during the perioperative interval using a patient-specific strategy. The guidance on decision-making with regard to perioperative aspirin cessation or continuation using currently available clinical data from studies in high-risk patients along with nonclinical aspirin studies is conflicting and does not enable a simplified or unified answer. However, pertinent guidelines on CV disease management provide a basic framework for aspirin management, and large trial findings provide some insight into the safety of perioperative aspirin cessation in some contexts, although uncertainty on perioperative aspirin still exists. This review provides an evidence-based update on perioperative aspirin management in patients undergoing noncardiac surgery with a focus on recommendations for perioperative clinicians on continuing versus holding aspirin during this context.

Introduction

Aspirin is integral to the management of cardiovascular (CV) disease (including coronary artery disease [CAD], cerebrovascular disease [CVD], and peripheral arterial disease [PAD]) and is consequently one of the most widely used medications in the world.[1] In the United States, aspirin is prescribed to up to 5% of adults on a long-term basis,[2] and more than 6 million people take aspirin daily without a clinician's recommendation.[3] The evidence and indications for aspirin use continuously evolve, and recent trials question its efficacy in certain contexts, such as primary prevention.[4,5]

Up to 5% of all surgical patients over 45 years old experience a major adverse CV event (MACE) within 30 days of surgery.[6] Myocardial infarction (MI) is the most common cause of perioperative mortality, and the risk of death from a perioperative MI within 30 days of surgery is 10%.[7–11] Although one third of patients undergoing noncardiac surgery who are at risk for major CV complications receive aspirin during the perioperative period, uncertainty remains about how aspirin should be optimally managed perioperatively, and significant practice variability remains.[12–16] Limited evidence suggests that continuing aspirin prevents MACE in high-risk patients undergoing noncardiac surgery.[16–18] The risks of stopping perioperative aspirin may be amplified by the proinflammatory hypercoagulable state engendered by surgery potentially leading to acute thrombosis and myocardial ischemia.[15,19] Moreover, an aspirin withdrawal phenomenon has been postulated, further increasing these thrombotic risks and attendant sequelae.[19–21] Conversely, aspirin increases the risk of surgical bleeding potentially leading to hemodynamic instability and myocardial ischemia from supply-demand mismatch.

This review provides a comprehensive, evidence-based update on aspirin management during noncardiac surgery. It summarizes the most recent literature for the use of aspirin in the primary and secondary prevention of CV disease, the evidence for continuing or stopping aspirin in different subsets of patients undergoing noncardiac surgery, and provides management recommendations for the perioperative clinician. We performed a comprehensive PubMed and Medline literature search using the keywords: aspirin, aspirin withdrawal, perioperative, CAD, CVD, peripheral artery disease, and CV disease; we manually reviewed all relevant citations for inclusion.

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