POISE-2: Aspirin + Clonidine in Non-Cardiac Surgery

Periop aspirin = more bleeding, no MI benefit. Clonidine = more hypotension/cardiac arrest, no MI benefit.

Population

10,010 patients ≥45 yo with or at risk for atherosclerotic disease undergoing non-cardiac surgery.

Intervention

Two parallel arms. Aspirin: 200 mg pre-op + 100 mg/d × 30 days vs placebo. Clonidine: 0.2 mg pre-op + 0.2 mg patch × 72 hr vs placebo.

Comparison

Matching placebo for each.

Outcome

Composite of death + non-fatal MI at 30 days.

2×2 factorial double-blind RCT. Stratified by aspirin-naïve vs continuation. Bleeding + hypotension as key safety outcomes.

• Aspirin: composite 7.0% vs 7.1% (NS). Major bleeding: 4.6% aspirin vs 3.8% placebo (HR 1.23, P=0.04).
• Continuation arm + initiation arm both showed bleed signal, no MI benefit.
• Clonidine: composite 7.3% vs 6.8% (NS). Hypotension: 47.6% vs 37.1% (HR 1.32, P<0.001). Non-fatal cardiac arrest: 0.3% vs 0.1% (HR 3.20, P=0.02).

Hold aspirin pre-op for non-cardiac, non-vascular surgery in patients without recent stent (<6 wk DES, <12 mo high-risk stent). Continue if recent stent — bleeding risk is acceptable to avoid stent thrombosis. Do NOT start clonidine perioperatively; the hypotension + cardiac arrest signal kills any theoretical sympatholytic benefit. Together POISE-1/-2 closed the door on most prophylactic preventive medication strategies in periop cardiac protection — focus instead on hemodynamic stability + targeted statin continuation.

• Excluded patients with recent (<6 wk) coronary stent — most stented patients should not stop aspirin.
• Did not address prophylactic statin initiation (other trials, mixed signal).
• Vascular surgery underrepresented; some experts still favor periop aspirin for that subgroup.

1. Is your aspirin hold protocol aligned with the recent stent rule, or do you hold for everyone 7 days pre-op?
2. Does anyone in your practice still reach for periop clonidine? What's the residual rationale?
3. How does POISE-2 interact with the older WAR-C trial that suggested aspirin benefit in select populations?