A Comprehensive Update on Aspirin Management During Noncardiac Surgery

Conclusions and Recommendations

The optimal management of aspirin in the perioperative period continues to evolve in parallel with emerging new data involving CV disease management. Perioperative aspirin management balances the inherent thromboembolic risks of cessation against the bleeding risks associated with continuation. Hence, patient-specific CV risk factors including disease severity and coexisting therapies (ie, PCI) with associated specific risks (Table 5) along with the planned surgical or procedural activities all need to be considered in the aggregate with all decision-making. Nonetheless, recommendations on perioperative aspirin cessation or continuation using the available clinical data from studies in high-risk patients along with the nonclinical aspirin studies is conflicting and does not enable a simplified or unified answer. This may be due to in part to variations in study methodology, including the definitions of high-risk patients, high-risk surgeries, aspirin dosing, and use of nonaspirin anticoagulants.

Although pertinent ACC/AHA guidelines on CV disease management provide a basic framework for aspirin management and the POISE-2 trial findings provide some insight into the safety of perioperative aspirin cessation in some contexts, much uncertainty on perioperative aspirin still exists. Although the findings of POISE-2 suggest that continuation does not confer a CV benefit and may be harmful due to excess blood loss, there are multiple study-related issues that obfuscate whether temporary aspirin cessation in high-risk patients is safe or not. High-risk patients taking lifelong aspirin for a guideline-based primary or secondary indication should likely have their aspirin therapy continued throughout the perioperative period for the majority of surgical and interventional procedures except when undergoing a closed-space procedure, intramedullary spine, or transurethral prostate surgery. The following recommendations are a synthesis of available data. See the Figure for a guide to decision-making in patients taking aspirin who present for elective noncardiac surgery.

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Figure.

Decision-making recommendations for patients taking aspirin who present for elective surgery.

1. For the majority of patients using aspirin for primary CV disease prevention, preoperative aspirin cessation is safe. See Table 1. It should be highlighted that the current literature underpinning primary prevention recommendations is derived from a context outside the perioperative period and does not specifically address the cessation versus continuation risks and benefits in this context. Importantly, many patients start aspirin without seeking a physician's opinion; hence, careful attention to identifying self-prescribing of aspirin should be part of routine perioperative assessment. In these patients, the drug may be safely discontinued 7 days preoperatively, as by definition, it is being used for primary prevention and there should be full return of platelet function in this timeframe.

2. For patients prescribed aspirin for secondary prevention but without a coronary stent, it is not fully clarified as to the safety of preoperative aspirin cessation. This lack of direction is a function of POISE-2's exclusion of this high-risk patient group, as well as a continued paucity of prospective data specifically addressing this issue. The limited data that do exist suggest that continuing aspirin might be prudent, but data that are more robust are needed. Nonetheless, as described in Table 2, noncoronary stented patients with high CV disease risk should likely have aspirin continued throughout the perioperative period unless undergoing closed-spaced procedure or procedure with high-bleeding risk that is not easily controlled (ie, transurethral urologic procedures).

The overall dataset for the reduction of MACE by the continuation of antiplatelet agents in stable ischemic heart disease patients undergoing noncardiac surgery is negative. In the context of recent ACS, patients should ideally be on DAPT for 1 year, but if surgery is urgent (ie, cancer operation), it should proceed while continuing aspirin monotherapy at a minimum. Recent data suggest that, in the absence of noncardiac surgery, a shortened duration of DAPT appears safe with the continuation of monotherapy as outlined above; whether this extends to those undergoing noncardiac surgery remains unknown.

   3. For patients with CVD and PAD, there are also minimal prospective data, but the totality of observational data and guideline recommendations suggest stopping preoperative aspirin is associated with significant risk, especially within the timeframes described in Table 2, and likely should be continued throughout the perioperative period.

Anesth Analg. 2020;131(4):1111-1123. © 2020 International Anesthesia Research Society