Perioperative Aspirin Management
Continuation of aspirin in patients previously treated with aspirin should be considered in the perioperative period, with discontinuation only in those where hemostasis is difficult to control during surgery. 1
General Principles for Aspirin Management Before Surgery
The decision to continue or discontinue aspirin before surgery depends on balancing the thrombotic risk versus bleeding risk:
Patients Who Should Continue Aspirin Through Surgery:
- Patients with coronary stents (especially within 6-12 months of placement) 2
- Patients undergoing CABG (coronary artery bypass grafting) 1
- Patients undergoing minor surgical or endoscopic procedures 1
- Patients undergoing low-risk procedures (minor dental/dermatologic procedures, cataract surgery) 2
- Patients with recent acute coronary syndrome 2
Patients Who Should Discontinue Aspirin:
- Patients taking aspirin for primary prevention 3
- Patients undergoing neurosurgery, spinal surgery, or other closed-space procedures 2, 4
- Patients with underlying bleeding disorders 1
- Patients undergoing procedures where even minor bleeding can lead to severe complications 5
Timing of Aspirin Discontinuation
When aspirin discontinuation is necessary:
- For most elective non-cardiac surgeries: Stop aspirin 3-7 days before surgery 2
- For neurosurgery and spinal procedures: Stop aspirin 7-10 days before surgery 4
- For high bleeding risk procedures: Stop aspirin 7-10 days before surgery 1
Specific Surgical Scenarios
Coronary Artery Bypass Grafting (CABG):
- Patients already taking aspirin should continue it through the perioperative period 1
- For patients not already on aspirin, it should be started within 6 hours postoperatively 1
- Continuation of aspirin until CABG is associated with increased chest tube drainage but not with increased reoperation rates 1, 6
Non-Cardiac Surgery:
- For patients with coronary stents: Continue aspirin throughout the perioperative period 2
- For patients with high cardiovascular risk but no stents: Consider continuing aspirin unless undergoing closed-space surgery 3
- For patients with low cardiovascular risk: Discontinue aspirin 3-7 days before surgery 2
Spine Surgery:
- Stop aspirin 7-10 days before surgery to minimize risk of epidural hematoma 4
- Continuing aspirin or stopping it just 3-7 days before spine surgery increases bleeding complications 4
Postoperative Aspirin Management
- Resume aspirin within 24-48 hours after surgery when adequate hemostasis is achieved 2
- For patients with coronary stents, aspirin should be restarted as soon as possible (within 48 hours) 2
- For CABG patients, aspirin should be continued or initiated within 6 hours postoperatively 1
Important Considerations and Caveats
- Bleeding Risk: Aspirin increases bleeding risk by approximately 1.5 times but does not typically lead to higher severity bleeding complications 1
- Thrombotic Risk: Discontinuing aspirin in high-risk cardiovascular patients may increase risk of perioperative stroke 7
- Platelet Function: Aspirin irreversibly inhibits platelet function for the lifespan of the platelet (7-10 days) 5
- Monitoring: When continuing aspirin perioperatively, monitor for excessive bleeding and be prepared for platelet transfusion if necessary 2
Special Populations
- Patients with Drug-Eluting Stents: Ideally delay elective surgery for 6-12 months after stent placement 2
- Patients with Bare-Metal Stents: Ideally delay elective surgery for 4-12 weeks after stent placement 2
- Patients on Dual Antiplatelet Therapy: Consider continuing aspirin while discontinuing the P2Y12 inhibitor (clopidogrel, ticagrelor, prasugrel) 2
The decision to continue or discontinue aspirin before surgery requires careful assessment of both thrombotic and bleeding risks, with the understanding that continuing aspirin increases bleeding risk but may decrease thrombotic complications in high-risk patients.