Weighing the Risks of Perioperative Aspirin

Abstract

Neurosurgeons are wary of perioperative aspirin use given the potentially catastrophic effects of intraoperative or postoperative bleeding. In a poll of German spine surgeons, only 7 of 142 surgeons would perform elective surgery on a patient taking aspirin (3). With the exception of endovascular procedures, aspirin is generally discontinued 7e10 days before surgery. This time scale is derived from recommendations made by the American College of Chest Physicians and may be adjusted depending on the patient’s specific cardiac risk (2). No recommendations exist at the present time regarding the appropriate time period to restart aspirin postoperatively, leaving this decision to the surgeon. When considering perioperative aspirin use, the objective is to balance the risks of perioperative and postoperative hemorrhage against myocardial infarction and stroke. Neurosurgical literature to guide this decision-making process is sparse, especially in regard to intracranial surgery. In terms of aspirin use in spine surgery, only 2 recent publications address the topic, but these studies evaluated only estimated blood loss intraoperatively and postoperatively via wound drains (4, 5). The studies failed to address whether aspirin use was associated with hemorrhagic complications or if its discontinuation predisposed patients to cardiac events. A recent article in the New England Journal of Medicine (1) attempts to answer this question. Devereaux et al. (1) published their study as part of the POISE-2 (PeriOperative ISchemic Evaluation-2) trial. This prospective, randomized, multicenter, controlled trial sought to determine the effect of perioperatively administered aspirin versus placebo on the 30-day risk of death or nonfatal myocardial infarction in patients undergoing noncardiac surgery. Secondary outcome measures included risk ofmajor bleeding at the surgical site or elsewhere, risk of stroke, and the effect of coadministered clonidine. Only patients with cardiovascular risk factors, who could benefit from aspirin use, were included in the study. Patients were recruited for enrollment from 135 hospitals in 23 countries. Patients undergoing intracranial surgery were excluded. The study enrolled 10,010 patients divided into patients already taking aspirin (continuation stratum; n1⁄4 4382 patients) and patients not taking aspirin (initiation stratum; n 1⁄4 5628 patients) at the start of the trial. Patients from both strata were randomly assigned to either the aspirin group (n1⁄4 4998 patients) or the placebo group (n 1⁄4 5012 patients). Patients received 200 mg of aspirin or placebo just before surgery and continued themedication