How long should Aspirin (Acetylsalicylic Acid) be stopped before and after surgery?

Perioperative Aspirin Management: Timing of Discontinuation and Resumption

For elective surgery requiring aspirin interruption, aspirin should be stopped ≤7 days before surgery and resumed within 24 hours after surgery when adequate hemostasis is achieved. 1

Preoperative Aspirin Discontinuation

Timing of Discontinuation

• Standard recommendation: Stop aspirin ≤7 days before elective surgery when interruption is required 1
• Not 7-10 days: The traditional 10-day discontinuation period is unnecessary for most surgeries 2
• Surgery-specific considerations:
  • High bleeding risk procedures (neurosurgery, spinal surgery): Stop aspirin 7-10 days before surgery 3, 4
  • CABG surgery: Continue aspirin throughout the perioperative period 1, 3
  • Low bleeding risk procedures (minor dental/dermatologic procedures, cataract surgery): Aspirin can typically be continued 3

Physiological Basis

• Aspirin irreversibly inhibits platelet function for the lifespan of the platelet (7-10 days) 2
• Studies show that bleeding times normalize within 96 hours and platelet function tests normalize within 144 hours (6 days) after stopping aspirin 5
• No demonstrable hemostatic defect persists beyond the sixth day after treatment cessation 5
• No apparent difference in duration of effect between low-dose (75 mg) and higher-dose (300 mg) aspirin 5

Postoperative Aspirin Resumption

Timing of Resumption

• Resume within 24 hours: For most surgeries, resume aspirin ≤24 hours after surgery rather than >24 hours 1, 3
• CABG surgery: Resume aspirin within 24 hours after surgery 1
• High thrombotic risk patients: Resume as soon as possible (within 48 hours) after surgery 3

Considerations for Resumption

• Ensure adequate hemostasis before restarting 3
• Maximal antiplatelet effect occurs within minutes after taking aspirin 1
• Patients with coronary stents should have aspirin restarted as soon as possible to prevent stent thrombosis 3

Special Considerations

High Cardiovascular Risk Patients

• Patients with recent coronary stents:
  • For drug-eluting stents (DES): Delay elective surgery for 6-12 months if possible 3
  • For bare metal stents (BMS): Delay elective surgery for 4-12 weeks if possible 3
  • If surgery cannot be delayed, maintain aspirin throughout the perioperative period 3

Dual Antiplatelet Therapy

• For patients on dual antiplatelet therapy requiring surgery:
  • Consider maintaining aspirin while discontinuing P2Y12 inhibitors 3
  • P2Y12 inhibitor discontinuation timing:
    • Prasugrel: 7 days before surgery 1, 3
    • Clopidogrel: 5 days before surgery 1, 3
    • Ticagrelor: 3-5 days before surgery 1, 3

Common Pitfalls to Avoid

1. Stopping aspirin too early: Unnecessarily increases thrombotic risk 3
2. Not stopping aspirin when indicated: Increases bleeding risk in high-risk procedures 3, 4
3. Failing to resume aspirin promptly: Increases postoperative thrombotic risk 3
4. One-size-fits-all approach: The decision should consider both the bleeding risk of the procedure and the thrombotic risk of the patient 3
5. Overlooking the need for multidisciplinary discussion: Complex cases benefit from input from cardiology, surgery, and anesthesiology 3

Evidence Quality

The recommendations are based on conditional recommendations with very low to low certainty of evidence 1. Studies show conflicting results regarding bleeding complications with perioperative aspirin use, but recent evidence suggests that continuing aspirin may reduce major adverse cardiac events without significantly increasing bleeding complications in high-risk patients 6.