When should aspirin (acetylsalicylic acid) be discontinued prior to elective surgery?

From the Guidelines

Aspirin should be discontinued ≤ 7 days before elective surgery, as suggested by the most recent guidelines. This recommendation is based on the American College of Chest Physicians clinical practice guideline, which suggests stopping ASA ≤ 7 days instead of 7 to 10 days before the surgery 1. The decision to discontinue aspirin should be individualized based on the patient's specific circumstances, taking into account the risks of bleeding and thrombotic events.

• For patients taking aspirin for secondary prevention, the decision to discontinue requires careful consideration of both bleeding and thrombotic risks.
• In some high-risk cardiovascular cases or for certain cardiac, vascular, or neurological procedures, aspirin may be continued throughout the perioperative period.
• For patients taking aspirin only for primary prevention, it can generally be stopped ≤ 7 days before surgery and resumed once hemostasis is achieved, typically 24-48 hours after surgery. The French working group on perioperative haemostasis also recommends that aspirin should not be given for three days before the procedure, but this recommended duration may be adjusted 1. However, the most recent guideline from the American College of Chest Physicians suggests a discontinuation period of ≤ 7 days 1.
• The timeframe for discontinuation allows for the generation of new platelets, as aspirin irreversibly inhibits platelet function for their entire lifespan.
• The decision to discontinue aspirin should always be made in consultation with the patient's surgeon and cardiologist or primary physician to balance the risks of surgical bleeding against the risk of thrombotic events during the perioperative period.

From the Research

Aspirin Discontinuation Prior to Elective Surgery

• The optimal timing for aspirin discontinuation before elective surgery is a topic of ongoing debate, with various studies providing different insights 2, 3, 4, 5, 6.
• A systematic review and meta-analysis found that early discontinuation of aspirin (3-5 or more days before surgery) showed a decreased risk of peri-operative bleeding, with no difference in major adverse cardiac events (MACE) compared to late discontinuation or no discontinuation 2.
• Another study suggested that patients taking aspirin for primary prevention of cardiovascular disease should likely discontinue it during the perioperative period, especially when there is a high risk of bleeding, while patients with established cardiovascular disease may need to continue aspirin unless undergoing closed-space surgery 3.
• A randomized controlled trial found that preoperative aspirin administration resulted in neither a lower risk of death or thrombotic complications nor a higher risk of bleeding than placebo in patients undergoing coronary artery surgery 4.
• A preliminary study found that reducing the time of aspirin cessation from 7-10 days to 4-5 days is possible for patients using aspirin for secondary prevention without increased perioperative complications 5.
• A retrospective study suggested that late or no discontinuation of low-dose aspirin before coronary artery bypass grafting may decrease the risk of postoperative stroke without increased postoperative bleeding and need for blood transfusion 6.

Key Findings

• The risk of bleeding and thrombotic events should be balanced when deciding on aspirin discontinuation prior to elective surgery 2, 3, 4.
• The optimal timing for aspirin discontinuation may vary depending on the individual patient's risk factors and the type of surgery being performed 5, 6.
• Further studies are needed to provide more definitive guidance on aspirin management in the perioperative period 3.