A Meta-analysis of the Impact of Aspirin, Clopidogrel, and Dual Antiplatelet Therapy on Bleeding Complications in Noncardiac Surgery.

OBJECTIVE: The aim of this study was to determine the bleeding risks associated with single (aspirin) and dual (aspirin + clopidogrel) antiplatelet therapy (DAPT) versus placebo or no treatment in adults undergoing noncardiac surgery. SUMMARY OF BACKGROUND DATA: The impact of antiplatelet therapy on bleeding during noncardiac surgery remains controversial. A meta-analysis was performed to examine the risk associated with single and DAPT. METHODS: A systematic review of antiplatelet therapy, noncardiac surgery, and perioperative bleeding was performed. Peer-reviewed sources and meeting abstracts from relevant societies were queried. Studies without a control group, or those that only examined patients with coronary stents, were excluded. Primary endpoints were transfusion and reintervention for bleeding. RESULTS: Of 11,592 references, 46 studies met inclusion criteria. In a meta-analysis of >30,000 patients, the relative risk (RR) of transfusion versus control was 1.14 [95% confidence interval (CI) 1.03-1.26, P = 0.009] for aspirin, and 1.33 (1.15-1.55, P = 0.001) for DAPT. Clopidogrel had an elevated risk, but data were too heterogeneous to analyze. The RR of bleeding requiring reintervention was not significantly higher for any agent compared to control [RR 0.96 (0.76-1.22, P = 0.76) for aspirin, 1.84 (0.87-3.87, P = 0.11) for clopidogrel, and 1.51 (0.92-2.49, P = 0.1) for DAPT]. Subanalysis of thoracic and abdominal procedures was similar. There was no difference in RR for myocardial infarction [1.06 (0.79-1.43)], stroke [0.97 (0.71-1.33)], or mortality [0.97 (0.87-1.1)]. CONCLUSIONS: Antiplatelet therapy at the time of noncardiac surgery confers minimal bleeding risk with no difference in thrombotic complications. In many cases, it is safe to continue antiplatelet therapy in patients with important indications for their use.

Quality assessment of the literature on surgical quality improvement.

BACKGROUND: A proliferation of work on surgical quality improvement has brought about an increase in quality improvement publications. We assessed the quality of surgical quality improvement publications using the Standards of Quality Improvement Reporting Excellence (SQUIRE) guidelines. METHODS: We conducted a comprehensive review of the surgical quality improvement literature from 2008 to 2018. Articles were reviewed for concordance with 18 SQUIRE statements and 40 subheadings using a dichotomous (yes or no) scale. RESULTS: Fifty-five articles were included. No publication adhered to all 18 SQUIRE statements. On average, quality improvement publications met 11 out of 18 (61%) of the main statements and 26 out of 40 (65%) of the subheadings. Articles were concordant with introductory components, such as problem description (n = 55, 100%) and rationale (n = 52, 95%), but were less adherent to statements describing methodology, results, and discussion sections including measures (n = 7, 13%), results (n = 3, 5.5%), interpretation (n = 2, 3.6%), and conclusions (n = 2, 3.6%). Only 4 articles cited the SQUIRE guidelines (7.3%). Articles that cited SQUIRE were not more concordant to the statements than those that did not cite SQUIRE. CONCLUSION: Our analysis demonstrates that SQUIRE guidelines have not been adopted widely as a framework for the reporting of surgical quality improvement studies. Increased adherence to SQUIRE guidelines has the potential to improve the development and dissemination of surgical quality improvement projects.