34 ESC Guidelines

Patients on dual antiplatelet therapy

NCS-related bleeding risk

High bleeding risk
N
related to NCS

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Thrombotic risk
High thrombotic risk:
PCI <1 month or
N Y
ACS <3 months or
High risk of stent thrombosisa

Recommendations

Y Time-sensitive NCS

Interrupt P2Y12
Continue aspirin Bridge with GPI Defer NCS
inhibitorb Continue DAPT
(Class I) or cangrelorc (Class I)
(Class IIa/b)

Ticagrelor: 3–5 days

Clopidogrel: 5 days
Prasugrel: 7 days
(Class I)

Figure 5 Recommendations for management of antiplatelet therapy in patients undergoing non-cardiac surgery. ACS, acute coronary syndrome;
DAPT, dual antiplatelet therapy; GPI, glycoprotein IIb/IIIa inhibitors; PCI, percutaneous coronary intervention; N, no; NCS, non-cardiac surgery.
Y, yes; aHigh risk of peri-operative stent thrombosis defined by at least one of the following: history of stent thrombosis under antiplatelet therapy,
reduced left ventricular ejection fraction (,40%), poorly controlled diabetes, severely impaired renal function/haemodialysis, recent complex PCI (i.e.
severely calcified lesion, left main PCI, chronic total occlusion, bifurcational/crush technique, bypass graft PCI), or stent malapposition/residual dissection.
b
Timing of resumption after interdisciplinary risk assessment as soon as possible (within 48 h) after surgery. cFor dosing, see Figure 7.

The trial randomized 10 010 patients undergoing NCS with estab-
lished CVD, or who were at increased CV risk, to aspirin or placebo.
Patients were stratified according to whether they had not been tak-
ing aspirin before the study or were already on aspirin; 33% of the
patients had known vascular disease (23% CAD, 9% PAD, and 5%
stroke). Aspirin did not reduce the rates of death or non-fatal MI
at 30 days (7.0% vs. 7.1% in the placebo group [HR, 0.99; 95% CI,
0.86–1.15; P = 0.92]). Major bleeding was more common in the as-
pirin group than in the placebo group (4.6% vs. 3.8% [HR, 1.23; 95%
CI, 1.01–1.49; P = 0.04]). The primary outcome results were similar,
irrespective of whether or not patients had been taking aspirin be-
fore the study, and were also similar in patients with and without
vascular disease.
In a post hoc analysis of 470 patients (,5%) who had undergone
previous PCI, aspirin use was associated with a significant reduction
in death or MI (HR, 0.50; 95% CI, 0.26–0.95; P = 0.036) and MI alone
(HR, 0.44; 95% CI, 0.22–0.87; P = 0.021), while the risk of major or
life-threatening bleeding was not significantly increased in this set-
ting.244 Although the analysis carries several limitations, it supports
the perception that the ischaemic benefit of peri-operative aspirin
use outweighs the bleeding risk in patients with previous PCI.
Thus, among patients with previous PCI, in the absence of a very
high bleeding risk, low-dose aspirin should be continued during the
peri-operative period.
In patients undergoing transcatheter aortic valve implantation
(TAVI) who have no other indication for oral anticoagulant (OAC)
therapy, low-dose aspirin has been recommended as standard ther-
apy by recent guidelines based on an RCT.245,246 There are no ran-
domized data available assessing the withdrawal vs. continuation of
aspirin in patients after TAVI on aspirin alone undergoing NCS.
If the bleeding risk outweighs the potential CV benefit, aspirin
should be discontinued. For patients with high peri-operative bleed-
ing risk (e.g. undergoing spinal surgery or certain neurosurgical or
ophthalmological operations) aspirin should be discontinued for at
least 7 days.
On rare occasions, chronic coronary syndrome (CCS) patients
might be on clopidogrel monotherapy due to the results of recent
trials247 and the recommendations of the 2020 ESC Guidelines for