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Aspirin Before Elective Surgery-Stop or Continue?
Lili Plümer1, Moritz Seiffert, Mark Andree Punke
1Department of Anesthesiology, Center for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany; Department of General and Interventional Cardiology, University Heart Center Hamburg (UHZ), Hamburg, Germany; Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany.
Insights
Stopping aspirin before noncardiac surgery poses risks, especially for patients with coronary stents. Decisions to stop aspirin are influenced by factors like prior stent placement and bleeding concerns, highlighting a gap between guidelines and practice.
Area of Science:
- Cardiology
- Anesthesiology
- Clinical Practice Research
Background:
- Cessation of long-term aspirin therapy before noncardiac surgery increases cardiac event risk in high-risk patients.
- Patients with prior percutaneous coronary interventions (PCI) and stent implantation are particularly vulnerable.
- Factors influencing the decision to discontinue aspirin preoperatively are not well understood.
Purpose of the Study:
- To identify factors associated with the decision to stop long-term aspirin treatment before noncardiac surgery.
- To explore patient and anesthesiologist perspectives on preoperative aspirin use.
Main Methods:
- A single-center, cross-sectional study surveyed 805 patients on long-term aspirin and their anesthesiologists.
- Standardized questionnaires assessed preoperative aspirin use, comorbidities, and risk-benefit assessments.
- Multivariable logistic regression and intraclass correlations were used to analyze data.
Main Results:
- 46.8% of patients stopped aspirin pre-surgery, with many discontinuing at suboptimal times.
- Prior PCI with stent implantation reduced the likelihood of aspirin cessation (OR=0.47).
- Factors increasing cessation included prior discontinuation, bleeding risk, lack of understanding of aspirin's purpose, and short time to surgery.
Conclusions:
- Significant discordance exists between clinical guidelines and actual practice regarding aspirin cessation in patients with coronary stents.
- Early collaboration between cardiologists and anesthesiologists is crucial.
- Wider use of stent implant cards could improve guideline adherence.
Background:
Cessation of long-term aspirin treatment before noncardiac surgery can cause adverse cardiac events in patients at risk, particularly in those with previous percutaneous coronary interventions (PCI) with stent implantation. The factors influencing the clinical decision to stop aspirin treatment are currently unknown.
Methods:
In a single-center, cross-sectional study (retrospective registration: NCT03049566) carried out from February to December 2014, we took a survey among patients scheduled for noncardiac surgery who were under long-term aspirin treatment, and among their treating anesthesiologists using standardized questionnaires on preoperative aspirin use, comorbidities, and risk-benefit assessments. The main objective was to identify factors associated with the decision to stop aspirin treatment. The results of multivariable logistic regressions and intraclass correlations are presented.
Results:
805 patients were included in the study, and 636 questionnaires were returned (203 of which concerned patients with coronary stents). 46.8% of the patients stopped their long-term aspirin treatment before surgery; 38.7% of these patients stopped it too early (>10 days before surgery) or too late (≤ 3 days before surgery). A prior PCI with stent implantation lowered the probability of aspirin cessation (odds ratio [OR] = 0.47 [0.31; 0.72]; p <0.001). On the other hand, patients were more likely to stop their long-term aspirin treatment if it had already been discontinued once before (OR = 4.58 [3.06; 6.84]; p <0.001), if there was a risk of bleeding into a closed space (OR = 4.54 [2.02; 10.22]; p <0.001), if they did not know why they were supposed to take aspirin (OR = 2.12 [1.05; 4.28]; p = 0.036), or if the preoperative consultation with the anesthesiologist occurred <2 days before surgery (OR = 1.60 [1.08; 2.37]; p = 0.018). Patients often assessed the risks related to aspirin cessation lower than their physicians did.
Conclusion:
This study reveals discordance between guideline recommendations and everyday clinical practice in patients with coronary stents. The early integration of cardiologists and anesthesiologists and a more widespread use of stent implant cards could promote adherence to the guidelines.
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