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Background  Perioperative antiplatelet agents potentially increase bleeding after non– ST ‐segment elevation ( NSTE ) acute coronary syndromes ( ACS ). The protease‐activated receptor 1 antagonist vorapaxar reduced cardiovascular events and was associated with increased bleeding versus placebo in  NSTE ACS , but its efficacy and safety in noncardiac surgery ( NCS ) remain unknown. We aimed to evaluate ischemic, bleeding, and long‐term outcomes of vorapaxar in  NCS  after  NSTE ACS .    Methods and Results  In the  TRACER  trial, 2202 (17.0%) patients underwent major or minor  NCS  after  NSTE ACS  over 1.5 years (median); continuing study treatment perioperatively was recommended. The primary ischemic end point for this analysis was cardiovascular death, myocardial infarction, stent thrombosis, or urgent revascularization within 30 days of  NCS . Safety outcomes included 30‐day  NCS  bleeding and  GUSTO  moderate/severe bleeding. Overall, 1171 vorapaxar and 1031 placebo patients underwent  NCS . Preoperative aspirin and thienopyridine use was 96.8% versus 97.7% ( P =0.235) and 89.1% versus 86.1% ( P =0.036) for vorapaxar versus placebo, respectively. Within 30 days of  NCS , no differences were observed in the primary ischemic end point between vorapaxar and placebo groups (3.4% versus 3.9%; adjusted odds ratio 0.81, 95%  CI  0.50 to 1.33,  P =0.41). Similarly, no differences in  NCS  bleeding (3.9% versus 3.4%; adjusted odds ratio 1.41, 95%  CI  0.87 to 2.31,  P =0.17) or  GUSTO  moderate/severe bleeding (4.2% versus 3.7%; adjusted odds ratio 1.15, 95%  CI , 0.72 to 1.83,  P =0.55) were observed. In a 30‐day landmarked analysis,  NCS  patients had a higher long‐term risk of the ischemic end point (adjusted hazard ratio 1.62, 95%  CI  1.33 to 1.97,  P <0.001) and  GUSTO  moderate/severe bleeding (adjusted hazard ratio 5.63, 95%  CI  3.98 to 7.97,  P <0.001) versus patients who did not undergo  NCS , independent of study treatment.    Conclusion   NCS  after  NSTE ACS  is common and associated with more ischemic outcomes and bleeding. Vorapaxar after  NSTE ACS  was not associated with increased perioperative ischemic or bleeding events in patients undergoing  NCS .

Efficacy and Safety of Vorapaxar in Non– ST ‐Segment Elevation Acute Coronary Syndrome Patients Undergoing Noncardiac Surgery