A Meta-analysis of the Impact of Aspirin, Clopidogrel, and Dual Antiplatelet Therapy on Bleeding Complications in Noncardiac Surgery

Columbo, Jesse A.; Lambour, Andrew J.; Sundling, Rebecca A; Chauhan, Nirali B.; Bessen, Sarah Y.; Linshaw, David L.; Kang, Ravinder; Riblet, Natalie; Goodney, Philip P.; Stone, David H.

doi:10.1097/sla.0000000000002279

Cited by 82 publications

(48 citation statements)

References 30 publications

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“…A previous study showed that perioperative antiplatelet therapy for noncardiac surgery confers minimal bleeding risk with no thrombotic complications, which indicated that antiplatelet therapy was safe perioperatively [5]. This was in agreement with the results of the current study.…”

Section: Discussionsupporting

confidence: 93%

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Effect of Antithrombotic Therapy on Secondary Bleeding After Proctological Surgery

Maemoto¹,

Tsujinaka²,

Miyakura³

et al. 2020

Preprint

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Background: The purpose of this study was to identify the incidence and severity of secondary bleeding after proctological surgery for patients with or without antithrombotic therapy.Methods: We retrospectively identified 113 patients who underwent proctological surgery in our hospital from March 2009 to February 2019. In general, antiplatelet drugs were continued and anticoagulant drugs were either substituted or withdrawn prior to the surgery. The severity of secondary bleeding was classified as mild, moderate, severe.Results: Eighteen patients underwent antiplatelet therapy (A group) and 95 patients did not undergo antithrombotic therapy (N group). Secondary bleeding was observed in nine patients (8.0%) and patients in the A group exhibited significantly higher rate of secondary bleeding rate than patients in the N group (39% vs. 2.4%, P < 0.01). The median interval from surgery to the onset of secondary bleeding was 5 (range: 0-11days). The severity of bleeding was the highest in patients administered direct oral anticoagulants (DOAC) and was the lowest in those administered aspirin. There was no mortality or cardiovascular event.Conclusions: Antithrombotic therapy is associated with high risk of secondary bleeding after proctological surgery, particularly in patients who undergo anticoagulant therapy. Delaying of postoperative resumption of anticoagulants may be considered in balancing the individual risk of postoperative thromboembolic complications against the risk of secondary bleeding. Future prospective studies with larger number of patients are needed to determine the appropriate timing of resuming antithrombotic therapy.

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Section: Discussionsupporting

confidence: 93%

“…Several studies have evaluated the bleeding risk in patients who require noncardiac surgery with antithrombotic drugs [5,6,7]. Despite an increased risk of transfusion, continuing antithrombotic therapy during a noncardiac surgery is feasible.…”

Section: Introductionmentioning

confidence: 99%

Effect of Antithrombotic Therapy on Secondary Bleeding After Proctological Surgery

Maemoto¹,

Tsujinaka²,

Miyakura³

et al. 2020

Preprint

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“…One of the clinical trials analyzed in our review was conducted in the United States, probably because almost a third of the North American population uses ASA, which is a cause for concern for physicians, because parallel to this there was also the increase in the number of noncardiac surgeries undergone by these patients in this country. 14 , 20 , 26 , 32 The other and last clinical trial was carried out in Serbia, a finding that can be understood by the results of the EPICOR study published in 2012, 33 which sought to identify regional differences in the use of antiplatelet agents for the treatment of acute coronary syndrome and showed that North and South Europe represent more expressive consumption of these drugs than countries of Eastern Europe and Latin America.…”

Section: Discussionmentioning

confidence: 99%

“…Thus, surgeons are frequently confronted with decision-making on whether or not to discontinue antiplatelet therapy during the perioperative period for noncardiac surgeries, 15 , 17 , 20 because they must take into account the potential protective effect of antiplatelet therapy vs the risk of bleeding caused by these drugs; 15 , 17 so, there is no unanimous opinion among medical professionals, regardless of whether the patient’s use of antiplatelets is intended for primary or secondary prevention of cardiovascular events. 20 , 21…”

Section: Introductionmentioning

confidence: 99%

Antiplatelet agents in perioperative noncardiac surgeries: to maintain or to suspend?

Borges¹,

Carvalho²,

Gomes³

et al. 2018

TCRM

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BackgroundWhen prescribing antiplatelet agents, physicians face the challenge of protecting patients from thromboembolic events without inducing bleeding damage. However, especially in the perioperative period, the use of these medications requires a carefully balanced assessment of their risks and benefits.ObjectiveTo conduct a systematic review to check whether the antiplatelet agent is to be maintained or suspended in the perioperative period of noncardiac surgeries.Search strategyA comprehensive literature search using Science Direct, Scopus, MEDLINE-PubMed, and Web of Science was undertaken.Selection criteriaClinical trials of noncardiac surgeries with patients taking regular anti-platelet therapy, published between 2013 and 2018.ResultsA total of 1,302 studies were initially identified, with only four meeting the inclusion criteria. The selected studies were conducted in different countries such as, including India (2), Serbia (1), and the USA (1). The age group was similar in all studies, from 61 to 75 years. The most frequent surgery was related to tooth extraction and transurethral resection of bladder cancer. There was a group of patients who used single antiplatelet agents and groups who used single therapy and double therapy. Acetylsalicylic acid was the common drug in all studies.ConclusionIt was concluded that the clinical trials were classified as good quality and that it was not necessary to suspend antiplatelet therapy prior to surgical procedures such as dental extraction and transurethral resection of bladder cancer. It should be noted that it is necessary to jointly evaluate the type of antiplatelet agent, the thrombotic risk of the patient, and the hemorrhagic risk of the surgical procedure.

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“… 9 However, although the use of antiplatelet agents has increased cardiovascular safety of many patients, 10 when they need a non-cardiac surgery, surgeons and anesthesiologists frequently have to face the decision of whether to interrupt or not antiplatelet therapy in those patients during the perioperative period considering the risks of the occurrence of thrombi or bleedings, respectively. 11 - 13 …”

Section: Introductionmentioning

confidence: 99%

Factors Associated with Inadequate Management of Antiplatelet Agents in Perioperative Period of Non-Cardiac Surgeries

Borges¹,

Almeida²,

Filho³

et al. 2018

Arquivos Brasileiros De Cardiologia

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BackgroundThe current guidelines dispose recommendations to manage antiplatelet agents in the perioperative period; however, the daily medical practices lack standardization.ObjectivesTo asses factors associated with inadequate management of antiplatelet agents in the perioperative period of non-cardiac surgeries.MethodsCross-sectional Study conducted in hospital from October 2014 to October 2016. The study dependent variable was a therapy that did not comply with the recommendations in the Brazilian Association of Cardiology (SBC) guidelines. The independent variables included some characteristics, the people in charge of the management and causes of lack of adherence to those guidelines. Variables were included in the multivariate model. Analysis was based on the odds ratio (OR) value and its respective 95% confidence interval (CI) estimated by means of logistic regression with 5% significance level.ResultsThe sample was composed of adult patients submitted to non-cardiac surgeries and who would use acetylsalicylic acid (aspirin) or clopidogrel (n = 161). The management failed to comply with the recommendations in the guidelines in 80.75% of the sample. Surgeons had the highest number of noncomplying orientations (n = 63). After multivariate analysis it was observed that patients with a higher level of schooling (OR = 0.24; CI95% 0.07-0.78) and those with a previous episode of acute myocardial infarction (AMI) (OR = 0.18; CI95% 0.04-0.95) had a higher probability of using a therapy complying with the guidelines.ConclusionPositive association between patients’ schooling level, or those with a history of previous AMI, with management of the use of aspirin and clopidogrel in the perioperative period of non-cardiac surgeries. However, diverging conducts stress the need of having internal protocol defined.

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A Meta-analysis of the Impact of Aspirin, Clopidogrel, and Dual Antiplatelet Therapy on Bleeding Complications in Noncardiac Surgery

Abstract: Antiplatelet therapy at the time of noncardiac surgery confers minimal bleeding risk with no difference in thrombotic complications. In many cases, it is safe to continue antiplatelet therapy in patients with important indications for their use.

Cited by 82 publications

References 30 publications

Effect of Antithrombotic Therapy on Secondary Bleeding After Proctological Surgery

Effect of Antithrombotic Therapy on Secondary Bleeding After Proctological Surgery

Antiplatelet agents in perioperative noncardiac surgeries: to maintain or to suspend?

Factors Associated with Inadequate Management of Antiplatelet Agents in Perioperative Period of Non-Cardiac Surgeries

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