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In the Perioperative Ischemic Evaluation 2 (POISE-2) trial (NEJM JW Cardiol May 2014 and N Engl J Med 2014; 370:1494), perioperative aspirin was found not to prevent the primary composite outcome of death and nonfatal myocardial infarction (MI) in patients undergoing noncardiac surgery. The investigators have now conducted a post hoc analysis of 470 patients with a history of previous percutaneous coronary intervention (PCI) who were included in POISE-2.
Baseline characteristics and medications were similar in the aspirin and placebo groups. Aspirin or placebo was started within 4 hours before surgery and continued throughout the perioperative period. Among patients with prior PCI, the primary outcome of death or nonfatal MI was less frequent in the aspirin group than the placebo group (14 vs. 27 patients; hazard ratio, 0.5), and the rate of MI alone was lower (5.1% vs. 11.0%), whereas among patients with no prior PCI, there were no significant differences in these outcomes between the aspirin and placebo groups. Aspirin did not significantly increase the risk for major or life-threatening bleeding in patients with prior PCI; however, because of significant heterogeneity, this observation should be interpreted with caution.
Graham MM et al. Aspirin in patients with previous percutaneous coronary intervention undergoing noncardiac surgery. Ann Intern Med 2017 Nov 14; [e-pub]. (http://dx.doi.org/10.7326/M17-2341)
Piccolo R and Windecker S.Low-dose aspirin to reduce the risk for myocardial infarction among patients with coronary stents undergoing noncardiac surgery. Ann Intern Med 2017 Nov 14; [e-pub]. (http://dx.doi.org/10.7326/M17-2954)
Comment
For most patients undergoing noncardiac surgery who have a history of PCI, aspirin should be utilized in the perioperative period irrespective of stent type; risks and benefits must be weighed in patients at extremely high risk for bleeding. For patients without prior PCI, the use of aspirin is not supported.