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Perioperative aspirin use?

 

Clinical bottom line

There are no trials informing on continuing using aspirin during the perioperative period. This decision-analysis indicated that continued use of aspirin may be preferable to stopping it.


Reference

DT Neilipovitz et al. The effect of perioperative aspirin therapy in peripheral vascular surgery: a decision analysis. Anesthesia & Analgesia 2001 93: 573-580.

Study

There are no trials informing on continuing using aspirin during the perioperative period, and any such trials would have to be very large and probably long in order to adequately capture enough relevant information. An alternative is a decision analysis based on a literature search.

Here a base-case scenario of a 65 year old white man undergoing infrainguinal revasularisation surgery, with epidural anaesthesia. Two strategies were compared:

  1. Discontinue aspirin throughout the perioperative period.
  2. Continue aspirin through the perioperative period.

The assumption was that long term effects of thrombotic complications were the same as outcomes in the non-operative setting. Seven possible outcomes were considered - operative death, myocardial infarction, thrombotic or haemorrhagic stroke, gastrointestinal bleed, incisional bleed, and event free survival.

Results

There were 138 articles reviewed for pertinent information. The results of the decision analysis are shown in Table 1. Continued aspirin administration decreased perioperative mortality, but with an increased risk of haemorrhagic complications.

Table 1: Decision analysis for a 65 year old man having infrainguinal revasularisation surgery

Outcome

No aspirin

Aspirin

Myocardial infarction (%)

4.61

2.71

Thrombotic CVA (%)

1.69

1.12

Haemorrhagic CVA (%)

0.37

0.59

Gastric bleed (%)

0.35

0.76

Incisional bleed (%)

5.88

7.71

All adverse events (%)

12.90

12.89

Mortality (%)

2.78

2.05

Crude life expectancy (years)

14.83

14.89

QALYs

14.72

14.79

A sensitivity analysis showed that aspirin was the preferred strategy except for low rates of infarction and high rates of incisional bleed.

Comment

Those with a professional interest in the use of anticoagulants during surgery will find this paper a very useful read. It demonstrates a method that could be used in other circumstances, and has a thoughtful discussion.