Aspirin During Noncardiac Surgery: Only in Patients with Prior Angioplasty

A new analysis from the POISE-2 study suggests that aspirin should not be withheld prior to noncardiac surgery in patients with a history of coronary angioplasty, even if their coronary procedure occurred several years earlier.

Patients with a history of coronary angioplasty who need cardiac surgery are more likely to benefit from continued aspirin therapy, thus avoiding thrombosis, instead of being harmed by the risk for bleeding. This is a post-hoc analysis of the original study, which means that the outcomes are hypothesis-generating conclusions (that are as interesting as always).

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The original POISE-2 study was conducted at 135 centers in 35 countries, and it randomized 10,010 patients who required noncardiac surgery to perioperative aspirin or placebo. The trial found no difference between groups as regards death or infarction at 30 days, but did see an increased risk of bleeding in the aspirin group.

The current analysis, which was not prespecified in the original study, focused on the 470 randomized patients who had previously undergone coronary angioplasty.

Patients who had received a drug-eluting stent within 1 year and a bare-metal stent within 6 weeks before the procedure were excluded from the analysis due to already existing evidence in favor of continuing aspirin administration.

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The mean time from angioplasty to surgery was 64 months (5.3 years) and most patients had received a bare-metal stent.

As opposed to what was seen for the overall trial, patients with prior angioplasty derived significant benefit from aspirin, as it reduced the risk of death and infarction at 30 days (6% vs. 11.4%; hazard ratio [HR]: 0.5). Such difference was basically driven by infarction, since the risk for mortality and, also importantly, the risk for bleeding were similar among groups.

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An additional analysis on prior coronary disease per se was negative. Only prior stent angioplasty would warrant continuing aspirin therapy.

Original title: Aspirin in Patients with Previous Percutaneous Coronary Intervention (PCI) Undergoing Noncardiac Surgery: The POISE-2 PCI Substudy.

Reference: Graham MM et al. American Heart Association 2017 Scientific Sessions.

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