Dr. Murat Yiğitbaşı

Name of the Study: Aspirin Monotherapy vs No Antiplatelet Therapy in Stable Patients With Coronary Stents Undergoing Low-to-Intermediate Risk Noncardiac Surgery (ASSURE DES)

Published in Congress: ESC Congress 2024

Link: Full Text

https://www.sciencedirect.com/science/article/pii/S0735109724081968

Background

Current guidelines recommend the continuation of aspirin perioperatively in patients with coronary drug-eluting stents (DES) undergoing noncardiac surgery. However, there is limited supporting evidence for this recommendation.

Objective

This study aimed to compare the effects of continuing aspirin monotherapy versus temporarily discontinuing all antiplatelet therapy before noncardiac surgery in patients with previous DES implantation.

Methods

Patients who had received a DES more than one year prior and were undergoing elective noncardiac surgery were randomly assigned to either continue aspirin or discontinue all antiplatelet agents 5 days before the surgery. It was recommended that antiplatelet therapy should be resumed no later than 48 hours after surgery, unless contraindicated. The primary outcome was a composite of death from any cause, myocardial infarction, stent thrombosis, or stroke occurring from 5 days before to 30 days after noncardiac surgery.

Results

A total of 1,010 patients were randomized, with 926 patients included in the modified intention-to-treat population (462 in the aspirin monotherapy group and 464 in the no-antiplatelet therapy group). The primary composite outcome occurred in 3 patients (0.6%) in the aspirin monotherapy group and 4 patients (0.9%) in the no-antiplatelet therapy group (difference: 0.2 percentage points; 95% CI: -1.3 to 0.9; P > 0.99). There were no cases of stent thrombosis in either group. The incidence of major bleeding did not differ significantly between the groups (6.5% vs. 5.2%; P = 0.39), but minor bleeding was significantly more frequent in the aspirin group (14.9% vs. 10.1%; P = 0.027).

Conclusion

Among patients undergoing low-to-intermediate risk noncardiac surgery more than one year after stent implantation primarily with a DES, the study did not identify a significant difference between perioperative aspirin monotherapy and no antiplatelet therapy with respect to ischemic outcomes or major bleeding.

Interpretation

The study did not find a significant difference in ischemic outcomes—such as death, myocardial infarction, stent thrombosis, or stroke—between patients who continued aspirin and those who temporarily stopped all antiplatelet therapy. Although continuing aspirin did not raise the risk of major bleeding, it was linked to a higher rate of minor bleeding. These findings indicate that stopping aspirin may not significantly affect clinical outcomes in this patient group. However, due to the low number of events, larger studies are needed to confirm these results.