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

Perioperative Aspirin Management Guidelines

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 patient's thrombotic risk. 1

Timing of Aspirin Discontinuation by Surgery Type

High Bleeding Risk Procedures

• Neurosurgery, spinal surgery, intracranial procedures: Stop aspirin 7 days before surgery 1
• Cardiac surgery: Increased postoperative bleeding and blood product requirements when aspirin is continued 2, 3

Moderate Bleeding Risk Procedures

• Most non-cardiac surgeries: Stop aspirin 3-5 days before surgery 1
• Specific timing by P2Y12 inhibitor (for patients on dual antiplatelet therapy):
  • Ticagrelor: at least 3 days before surgery
  • Clopidogrel: at least 5 days before surgery
  • Prasugrel: at least 7 days before surgery 4

Low Bleeding Risk Procedures

• Minor dental/dermatologic procedures and cataract surgery: Aspirin can be continued throughout 1

Special Patient Populations

Patients with Coronary Stents

• Drug-eluting stents (DES):

  • Ideally delay elective surgery for 6-12 months after stent placement 1
  • If surgery cannot be delayed, maintain aspirin throughout the perioperative period 4, 1
  • For patients requiring dual antiplatelet therapy who need surgery during high thrombotic risk period, aspirin should be maintained while clopidogrel can be withdrawn for a 5-day window 4

• Bare-metal stents (BMS):

  • Delay elective surgery for at least 6 weeks after stent placement 1

Risk Assessment Framework

A multidisciplinary team approach is strongly recommended for patients with coronary stents or recent acute coronary syndrome, involving cardiologist, surgeon, anesthesiologist, and hematologist 4

Aspirin Resumption After Surgery

• Resume aspirin within 24 hours after surgery when adequate hemostasis is achieved 1
• For patients with coronary stents, restart as soon as possible (within 48 hours) 4
• Consider loading dose of 300 mg clopidogrel when resuming treatment after surgery for patients on dual antiplatelet therapy 4

Evidence Considerations

The evidence suggests that aspirin discontinuation 5 days before surgery normalizes platelet function in healthy individuals 5. While some studies show increased bleeding with preoperative aspirin use 2, 3, others found no significant difference in major thrombotic or bleeding events between aspirin maintenance or interruption 6.

Common Pitfalls to Avoid

1. Stopping aspirin too early: Unnecessarily increases thrombotic risk
2. Not stopping aspirin when indicated: Increases bleeding risk in high-risk procedures
3. Failing to resume aspirin promptly: Increases postoperative thrombotic risk
4. Not considering individual patient factors: Bleeding vs. thrombotic risk must be weighed carefully
5. Lack of multidisciplinary discussion: Essential for complex cases, especially with coronary stents

The perioperative management of aspirin requires careful consideration of both bleeding and thrombotic risks, with decisions ideally made through a multidisciplinary approach, particularly for high-risk patients.