Should More Patients Continue Aspirin Therapy Before Surgery? http://ow.ly/aFqJO
Should More Patients Continue Aspirin Therapy Before Surgery?
By Megan Brooks
NEW YORK (Reuters Health) Apr 20 – The practice of empirically interrupting chronic aspirin therapy before surgery “should be abandoned,” according to the authors of a contemporary literature review.
They say the evidence they found in a PubMed and Medline literature search “strongly supports” continued perioperative use of aspirin in patients taking it for secondary prevention of coronary artery disease, cerebrovascular disease, and peripheral vascular disease.
“Many patients need to be on lifelong aspirin therapy for various cardiovascular indications and…other than for a select group of operative procedures, the risks of aspirin cessation exceed the benefit,” Dr. Neal Stuart Gerstein from the Department of Anesthesiology and Critical Care Medicine, University of New Mexico in Albuquerque told Reuters Health by email.
“Between a given patient’s underlying cardiovascular risk (the reason they take aspirin in the first place), the hypercoagulable state created by the surgical procedure, and the aspirin-withdrawal syndrome — a perfect storm is created that significantly increases the risk of a surgical patient having a cardiovascular thrombotic event such as a heart attack or stroke,” he added.
Routine discontinuation of aspirin seven to 10 days preoperatively is “unjustified,” he and his colleagues conclude in the Annals of Surgery for May.
But Dr. P.J. Devereaux from Ontario, Canada, who was not involved in the review, told Reuters Health it would be “premature to have physicians believe stopping ASA prior to surgery is clearly the wrong approach to patient management. The authors may be right but the evidence to support their position is very weak.” Dr. Devereaux is with the Population Health Research Institute, David Braley Cardiac, Vascular and Stroke Research Institute, Perioperative Medicine and Surgical Research Unit in Hamilton.
More than 50 million adults in the U.S. take aspirin daily for primary and secondary prevention of cardiovascular disease. Whether it’s best to stop or continue aspirin before having surgery is an unsettled issue at the moment. Stopping aspirin can cause a platelet rebound phenomenon and prothrombotic state leading to major adverse cardiac events, Dr. Gerstein and colleagues note in their report. But despite the risks of aspirin withdrawal, which are exacerbated during the preoperative period, it’s become standard practice to halt aspirin therapy before elective surgery for fear of excessive bleeding.
Based on their literature review, Dr. Gerstein and colleagues conclude that surgical procedures that involve particular anatomic locations, including middle ear, posterior chamber of the eye, intracranial, intramedullary spine and possibly transurethral prostatectomy (TURP) confer the highest risk of complicating hemorrhage while on aspirin therapy.
Aside from these types of procedures, they say, “the thromboembolic risks of aspirin cessation in the at-risk patient often outweigh the minor bleeding risks in the vast majority of operative procedures.”
The authors do emphasize, however, that nearly all of the available data they reviewed are observational and retrospective. There remains an “urgent need for prospective randomized trials to evaluate the optimal management strategy of perioperative aspirin therapy,” they say.
The POISE-2 trial, in which Dr. Devereaux is involved, promises to shed light on this issue. POISE-2 is a 10,000-patient randomized controlled trial that is evaluating the impact of perioperative ASA in patients undergoing noncardiac surgery.
“In this trial,” Dr. Deveraux told Reuters Health, “half the patients are taking chronic ASA and they have to stop it at least three days before surgery, and then they are randomized to restart low-dose ASA or placebo just prior to surgery and they continue it until day eight after surgery when they resume their normal ASA. The other half of the patients in POISE-2 are patients who do not take chronic ASA and they are randomized to start low-dose ASA or placebo just prior to surgery and they take the study drug daily until day 31 after surgery.”
“Over 20 countries are participating in this trial, and we have already randomized over 3,700 patients, and we are on track to complete recruitment in the summer of 2013. The independent data safety and monitoring committee evaluated unblinded data after the first 2500 patients completed their first 30-day follow-up and this committee was unanimous in their recommendation to continue the trial. Half of these patients were patients taking chronic ASA,” Dr. Devereaux noted.
Dr. Devereaux was also involved in a randomized controlled trial led by Dr. Jean Mantz from Beaujon University Hospital, Clichy, France, that was published in August 2011 in the British Journal of Anesthesia. That trial assessed the impact of preoperative maintenance or interruption of chronic aspirin therapy on thrombotic and bleeding events after elective non-cardiac surgery. In this study, Dr. Devereaux told Reuters Health, there was no increase in cardiovascular events in patients who had aspirin held preoperatively.
Ann Surg 2012.