Perioperative aspirin therapy in non-cardiac surgery: A systematic review and meta-analysis of randomized controlled trials

Background: Aspirin is a key element in prevention of cardiovascular and thromboembolic events. During non-cardiac surgery however, its balance of bleeding risks and benefits remains unclear. Methods: A systematic review and meta-analysis of randomized controlled trials was performed. Online databases were screened for clinical trials randomizing aspirin to no aspirin therapy in non-cardiac surgery. Clinical outcomes of all-cause mortality and cardiovascular mortality, arterial ischemic events, venous thromboembolic events and bleeding events were separately evaluated. Results: Seven RCTs comprising 28,302 patients were included. All-cause mortality (3.7% vs. 3.8%; odds ratio (OR) 0.97, Cl 0.86-1.10) and cardiovascular mortality (2.0% vs. 2.1%, OR 0.92; Cl 0.78-1.09) were not different in aspirin vs. no aspirin groups. Arterial ischemic events showed no differences, including myocardial infarction (2.5% (aspirin) vs. 2.5% (no aspirin)), cerebrovascular events (0.6% (aspirin) vs. 0.6% (no aspirin)) and peripheral arterial events (0.2% (aspirin) vs. 0.3% (no aspirin)). Aspirin significantly reduced the risk for venous thromboembolic events (VTE; 1.5% (aspirin) vs. 2.0% (no aspirin); OR 0.74, Cl 0.59-0.94, p = 0.02). Perioperative major bleeding was significantly more frequent in aspirin groups (4.4% vs. 3.7%; OR 1.18, CI 1.05 to 133, p = 0.007). Conclusion: Aspirin remained neutral with respect to overall survival, cardiovascular mortality and arterial ischemic events. It reduced venous thromboembolic events at the expense of perioperative major bleedings. Thus, this analysis supports recommendations against perioperative aspirin continuation/initiation in cardiovascular disease patients at intermediate risk, as well as recommendations of aspirin for VTE prophylaxis in orthopedic patients only. (C) 2017 Elsevier B.V. All rights reserved.