How long after coronary stent placement can aspirin (acetylsalicylic acid) be held for a short period for a procedure?

Perioperative Management of Aspirin After Coronary Stent Placement

For patients with coronary stents, aspirin should be maintained throughout most procedures, and should never be discontinued for at least 6-12 months after drug-eluting stent placement due to the high risk of stent thrombosis. 1

Timing Considerations Based on Stent Type

Drug-Eluting Stents (DES)

• First 6-12 months: Dual antiplatelet therapy (aspirin + clopidogrel) is mandatory 1
  • Absolutely no interruption of aspirin during this period
  • Stent thrombosis risk is highest during this window
• After 12 months: Limited interruption may be considered for high bleeding risk procedures 2

Bare Metal Stents

• First 4-6 weeks: Dual antiplatelet therapy must be maintained 1
• After 4-6 weeks: Risk of stent thrombosis decreases but aspirin should still be maintained when possible

Risk Stratification Algorithm for Aspirin Management

High Thrombotic Risk (Do NOT discontinue aspirin)

• DES placed within past 6-12 months 1
• History of stent thrombosis
• Multiple stents, long stents, or bifurcation stents
• Diabetic patients
• Low ejection fraction
• Incomplete revascularization

Procedure Bleeding Risk Assessment

1. Minor bleeding risk procedures:

   • Maintain both aspirin AND clopidogrel 1
   • Examples: dental procedures, minor dermatologic procedures

2. Intermediate bleeding risk procedures:

   • Maintain aspirin (75-162 mg daily)
   • Consider temporarily stopping clopidogrel for 5 days if >6 months post-DES 1
   • Resume clopidogrel as soon as possible after procedure

3. Major bleeding risk procedures:

   • If <6-12 months post-DES: Postpone procedure if possible 1
   • If procedure cannot be postponed and >12 months post-DES: Consider brief aspirin interruption (3-5 days) 2
   • Resume aspirin within 24-48 hours after procedure

Multidisciplinary Decision-Making

A multidisciplinary team meeting involving the cardiologist, surgeon/proceduralist, anesthesiologist, and hematologist should occur before any antiplatelet interruption 1. This is critical for:

1. Assessing individual thrombotic risk
2. Evaluating procedure-specific bleeding risk
3. Determining optimal perioperative antiplatelet management
4. Documenting the consensus plan in the medical record

Important Caveats and Pitfalls

• Never simultaneously discontinue both aspirin and clopidogrel in the first year after stent placement 1, 3
• Premature discontinuation of antiplatelet therapy increases stent thrombosis risk up to sevenfold 3
• For most dental and minor procedures, antiplatelet therapy should be continued without interruption 3
• If aspirin must be held, do so for the minimum time possible (ideally ≤3 days) 2
• Recent evidence suggests that for low-to-intermediate risk procedures performed >1 year after DES placement, brief aspirin interruption may be reasonable, though this remains controversial 2

Resumption of Therapy

• Resume aspirin within 24-48 hours after procedure unless absolutely contraindicated 1, 2
• Consider loading dose (325 mg) when restarting aspirin after interruption 1
• Monitor closely for signs of stent thrombosis (chest pain, ECG changes) if aspirin is interrupted

By following this algorithm and consulting with the patient's cardiologist, the risk of perioperative stent thrombosis can be minimized while accommodating necessary procedures.