Hot Line: Should aspirin be interrupted in patients with coronary stents undergoing non-cardiac surgery?
01 Sep 2024
“Current guidelines recommend continuing aspirin in patients with drug-eluting stents (DES) undergoing non-cardiac surgery;1 however, supporting evidence is limited. The ASSURE DES trial compared the efficacy and safety of continuing aspirin monotherapy vs. temporarily withholding all antiplatelet therapy around the time of non-cardiac surgery,” explained Doctor Jung-Min Ahn (Asan Medical Center - Seoul, South Korea).
ASSURE DES was an investigator-initiated, open-label trial, in which patients who had undergone DES implantation more than 1 year earlier, and who were now undergoing elective non-cardiac surgery, were randomised to continue aspirin or discontinue all antiplatelet therapy 5 days before surgery. Antiplatelets were recommended to be resumed no later than 48 hours after surgery, unless contraindicated. The primary outcome was a composite of death from any cause, myocardial infarction (MI), stent thrombosis or stroke between 5 days before to 30 days after non-cardiac surgery.
The trial included 926 patients, who had a mean age of 68.5 years and 24% were women. On average, DES was implanted 6.3 years before non-cardiac surgery and 84% had second-generation or newer stents. At randomisation, 39% of patients were on aspirin monotherapy, 23% on P2Y12 inhibitor monotherapy and 34% were on dual antiplatelet therapy.
There was no significant difference in the primary outcome between the groups at 30 days.
The primary outcome occurred in 0.6% of patients with aspirin and 0.9% with no antiplatelets (absolute difference −0.2 percentage points; 95% CI −1.3 to 0.9; p>0.99). Rates of the primary outcome events were low: 2 patients died from cardiac causes and 3 had an MI in the aspirin group, while 3 patients had an MI and 1 had a stroke in the no antiplatelets group.
Major bleeding rates were similar between the groups: 6.5% with aspirin and 5.2% with no antiplatelets (p=0.39), while minor bleeding was more frequent with aspirin (14.9% vs. 10.1%; p=0.027).
“Continuing aspirin monotherapy did not reduce ischaemic events, although it was associated with a modest increase in minor bleeding. The low event rate – which may reflect the safety profile of contemporary DES – led to the trial being underpowered and our overall findings should be interpreted with caution. However, it seems a flexible approach to perioperative antiplatelet management may be considered, without compromising patient safety,” concluded Dr. Ahn.
References
- Halvorsen S, et al. Eur Heart J. 2022;43:3826–3924.
