Continue or discontinue aspirin before non-cardiac surgery?

This commentary refers to ‘2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery’, by S. Halvorsen et al., https://doi.org/10.1093/eurheartj/ehac270 and the discussion piece ‘Diverging opinions for high bleeding risk patients’, by A.A. Başkurt, https://doi.org/10.1093/eurheartj/ehad245. We thank Dr. Baskurt for his interest in the 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery1 and his letter. He expresses concern regarding some diverging advice for high bleeding risk patients. The question is whether patients with a high bleeding risk should continue or discontinue aspirin before non-cardiac surgery. In the 2022 guidelines, it is recommended that patients with a previous percutaneous coronary intervention (PCI), continue aspirin peri-operatively if the bleeding risk allows (recommendation Table 13 in the 2022 ESC Guidelines.1 This recommendation is based primarily on a subgroup analysis of the Perioperative Ischemic Evaluation-2 (POISE-2) study.2 In patients with a very high peri-operative bleeding risk (e.g. undergoing spinal surgery or certain neurosurgical or ophthalmological operations), it is recommended that aspirin is discontinued for 7 days before surgery. The latter is an example of a clinical situation where the bleeding risk does not allow aspirin to be continued. We cannot see that these two recommendations diverge. Figure 5 in the 2022 ESC guidelines1 shows the recommended management of antiplatelet therapy in patients on dual antiplatelet therapy (DAPT) undergoing non-cardiac surgery. The indication for DAPT is usually a recent PCI or acute coronary syndrome. In the case of surgery with very high bleeding risk, the first advice would be to delay surgery until the recommended duration of DAPT has been completed. Then the P2Y12 inhibitor can be discontinued. With respect to aspirin, the same applies here as above; aspirin should be continued peri-operatively only if the bleeding risk allows. We ask for your understanding that not all clinical situations can be covered in detail in the figures or tables. Furthermore, in all challenging clinical situations, the management of antithrombotic therapy should be discussed between the surgeon and the cardiologist, so that the balance between the risk of life-threatening surgical bleeding and the risk of thrombosis can be considered. Not applicable. Ethical approval was not required. No data were generated or analysed for or in support of this paper. The authors declare no funding for this contribution.