Diverging opinions for high bleeding risk patients

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 ‘Continue or discontinue aspirin before non-cardiac surgery?’, by S. Halvorsen et al., https://doi.org/10.1093/eurheartj/ehad246. Dear editor, I have read the recent ‘2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery’ with great interest, published online in your journal. It has been a comprehensive guideline on the pre-operative evaluation of non-cardiac surgery for difficult-to-manage patients.1 However, I would like to draw your attention that there is a confusing mismatch between the flow chart in Figure 5, Table 9, recommendation Table 13, and the text in page 37 regarding the antithrombotic therapy management of the pre-operative patient. As explicitly stated in the text, whenever possible, in patients with an indication for dual antiplatelet therapy (DAPT), surgery should be performed without discontinuation of aspirin. According to the text, ‘Aspirin might be discontinued as a last measure only when there is very high bleeding risk with a comparably low ischaemic risk’, though, very high bleeding risk is not specifically addressed elsewhere. Furthermore, according to the recommendations in Table 13; for patients with high peri-operative bleeding risk (e.g. undergoing spinal surgery or certain neurosurgical or ophthalmological operations), it is stated that aspirin should be discontinued for at least 7 days (Class 1 recommendation). However, the flow chart in Figure 5 designates continuation of aspirin as a Class 1 recommendation for patients undergoing high bleeding risk surgery in the absence of high thrombotic risk.1 It looks like the text, figure, and recommendation tables were prepared by different people as I find it difficult to capture such diverging opinions. I would like to thank Prof. Dr. Mehmet Birhan Yilmaz for his help in writing this article. No new data were generated or analysed in support of this article.