From the Guidelines
Aspirin should not be discontinued prior to a procedure, unless the procedure carries a high risk of bleeding, in which case it is recommended to stop aspirin 5 days before the procedure. This recommendation is based on the most recent and highest quality study, which suggests that a three-day washout of aspirin leads to an improvement in platelet functions, but may not always be sufficient for full correction of platelet functions 1. The study also notes that the haemostatic safety threshold guaranteeing the absence of perioperative risk of bleeding associated with aspirin treatment has not been established, and that the functional platelet tests used in studies addressing this issue have yielded inconsistent results.
Key Considerations
- The decision to discontinue aspirin should be made on a case-by-case basis, taking into account the individual patient's risk of bleeding and thrombotic events 1.
- For patients with high cardiovascular risk, such as those with recent stent placement, history of stroke, or acute coronary syndrome, the decision to discontinue aspirin requires careful consideration and consultation with the patient's cardiologist or neurologist.
- Some minor procedures, such as dental work, cataract surgery, or minor dermatological procedures, may not require aspirin discontinuation.
- When stopping aspirin is necessary, it is recommended to resume it 24-48 hours after the procedure once hemostasis is achieved.
Rationale
- Aspirin affects platelets by irreversibly inhibiting cyclooxygenase, preventing thromboxane A2 production and impairing platelet aggregation.
- The effect of aspirin on platelets lasts for the platelet's lifespan, which is normally about 10 days, but may be shorter in some circumstances.
- The study suggests that faster recovery of aspirin-inhibited platelet function may occur in some patients, such as diabetics, patients with high weight, and those with thrombocytosis in a setting of myeloproliferative neoplasia 1.
From the Research
Aspirin Discontinuation Prior to a Procedure
- The decision to discontinue aspirin prior to a procedure depends on various factors, including the type of surgery, patient's cardiovascular risk, and potential bleeding risks 2, 3, 4.
- Studies suggest that low-dose aspirin may not need to be discontinued prior to most surgical procedures, except in cases where bleeding risks are high or the patient has a history of bleeding complications 3, 4.
- For patients with established cardiovascular disease, continuing aspirin during the perioperative period may be beneficial, unless the patient is undergoing closed-space surgery or has a high risk of bleeding 4.
- The risk of bleeding associated with aspirin use is generally considered low, and the benefits of continuing aspirin may outweigh the risks in many cases 2, 3, 5.
Specific Surgical Procedures
- For coronary artery bypass grafting surgery, the use of preoperative aspirin may increase the risk of bleeding, and the decision to continue or discontinue aspirin should be made on a case-by-case basis 5.
- For spine surgery, stopping low-dose aspirin 10 days or longer prior to surgery may be recommended to minimize the risk of hemorrhagic complications, although the optimal timing for discontinuation is still unclear 6.
- For other types of surgery, such as cardiovascular, vascular, and orthopedic surgery, the available evidence suggests that aspirin can be continued without a significant increase in bleeding risks 3.
Patient-Specific Factors
- Patients with a history of coronary stenting may require continued aspirin therapy throughout the perioperative period, unless the risk of bleeding is high 4.
- Patients with coagulation disorders or a history of bleeding complications may require aspirin to be discontinued prior to surgery, depending on the individual risk assessment 3, 4.
- The decision to discontinue aspirin should be made in consultation with the patient's healthcare provider, taking into account the individual patient's risk factors and medical history 2, 3, 4.