How long should aspirin (acetylsalicylic acid) be held prior to surgery?

Perioperative Aspirin Management

For most elective surgeries, aspirin should be discontinued 3-7 days before the procedure, with the exact timing depending on the type of surgery and the patient's thrombotic risk. 1

Surgery-Specific Recommendations

High Bleeding Risk Procedures

• Neurosurgery/Spinal/Intracranial surgery: Stop aspirin 7 days before surgery 1
• Non-cardiac surgery with high bleeding risk: Stop aspirin ≤7 days before surgery (typically 3-5 days) 1

Low Bleeding Risk Procedures

• Minor dental/dermatologic procedures and cataract surgery: Continue aspirin throughout 1
• Coronary artery bypass grafting (CABG): Continue aspirin throughout 2, 1
• Cesarean delivery: Continue aspirin throughout 1

Special Considerations for Coronary Stents

Drug-Eluting Stents (DES)

• If possible, delay elective surgery until at least 12 months after DES placement 2
• If surgery cannot be delayed:
  • Continue aspirin throughout the perioperative period if at all possible 2
  • If both aspirin and thienopyridine must be stopped due to very high bleeding risk:
    • Stop no sooner than 5 days before surgery
    • Restart as soon as possible after surgery, within 5 days 2

Bare-Metal Stents (BMS)

• Delay elective surgery for at least 4-12 weeks after BMS placement 2
• Continue aspirin throughout the perioperative period if possible 2

Resumption of Aspirin Therapy

• Resume aspirin within 24 hours after surgery once adequate hemostasis is achieved 1
• For patients with high cardiovascular risk, consider earlier resumption 1

Urgent Surgery Considerations

• For urgent surgeries where aspirin cannot be stopped in advance:
  • Proceed with awareness of increased bleeding risk
  • Consider platelet transfusion if significant bleeding occurs intraoperatively 1

Specific Recommendations for Cardiac Surgery

• For CABG: Non-enteric-coated aspirin (81-325 mg daily) should be administered preoperatively 2
• For patients on dual antiplatelet therapy requiring CABG:
  • Clopidogrel and ticagrelor should be discontinued at least 5 days before elective surgery 2
  • Prasugrel should be discontinued at least 7 days before elective surgery 2
  • For urgent CABG, clopidogrel and ticagrelor should be discontinued for at least 24 hours 2

Risk Assessment

• For patients on aspirin for secondary prevention of cardiovascular disease, the risk of thrombotic events with discontinuation (approximately 10% risk of all vascular events) must be weighed against the bleeding risk 3
• For patients on aspirin for primary prevention, the drug can be safely discontinued 7 days before surgery 1

Important Caveats

• Aspirin induces irreversible inactivation of platelet function that lasts 7-10 days 4
• There is no scientific evidence supporting the routine withdrawal of aspirin in all patients 5-10 days prior to surgery 4
• For heart patients in particular, continued use of aspirin may be beneficial unless the bleeding risk is extremely high 4
• For most surgeries except neurosurgery and procedures in closed spaces, the cardiovascular benefits of continuing aspirin may outweigh the bleeding risks 5

Remember that these recommendations represent general guidelines, and the final decision should consider the specific surgical procedure, the patient's cardiovascular risk, and the potential consequences of perioperative bleeding.