Should aspirin (acetylsalicylic acid) be continued peri-operatively?

Perioperative Aspirin Management

Aspirin should be continued perioperatively in patients with high cardiac risk, while it should be discontinued in patients undergoing elective noncardiac surgery without prior coronary stenting who have low cardiac risk. 1

Decision Algorithm for Perioperative Aspirin Management

Continue Aspirin When:

• Patient has undergone coronary stenting and is within the first 4-6 weeks after bare-metal stent (BMS) or drug-eluting stent (DES) implantation 1
• Patient is undergoing urgent noncardiac surgery and has coronary stents 1
• Patient is undergoing carotid endarterectomy 1
• Patient has established coronary artery disease and is undergoing renal transplantation 1
• Patient has high cardiac risk and the risk of ischemic events outweighs bleeding risk 1, 2

Discontinue Aspirin When:

• Patient is undergoing elective noncardiac noncarotid surgery without prior coronary stenting 1
• Patient is undergoing surgery with high bleeding risk (e.g., intracranial neurosurgery) 1
• Patient is taking aspirin for primary prevention only 3

Timing of Aspirin Discontinuation (If Required)

• For most surgeries: Last intake on day -3 (where day 0 is surgery day) 1
• For intracranial neurosurgery: Last intake on day -5 1

Special Considerations

For Patients with Coronary Stents:

• Critical recommendation: Continue dual antiplatelet therapy (DAPT) during urgent noncardiac surgery within 4-6 weeks of stent placement unless bleeding risk is prohibitive 1
• If P2Y12 inhibitors (clopidogrel, ticagrelor, prasugrel) must be discontinued, continue aspirin throughout the perioperative period 1
• Restart P2Y12 inhibitors as soon as possible after surgery 1

For High Bleeding Risk Procedures:

• Balance thrombotic and hemorrhagic risks through multidisciplinary discussion 1
• Consider platelet transfusion if emergency surgery is needed while on aspirin 1

Evidence Analysis

The 2014 ACC/AHA guidelines provide a Class IIb recommendation (Level of Evidence B) for continuing aspirin perioperatively when the risk of cardiac events outweighs bleeding risk 1. However, they also state that aspirin initiation or continuation is not beneficial (Class III: No Benefit) in patients undergoing elective noncardiac noncarotid surgery without prior coronary stenting 1.

The POISE-2 trial suggested discontinuing aspirin perioperatively, but this recommendation doesn't fully apply to high cardiac risk patients 2. Conversely, a smaller randomized trial by Oscarsson et al. found that perioperative aspirin reduced major adverse cardiac events by 80% in high-risk patients without increasing bleeding complications 4.

Common Pitfalls to Avoid

• Abrupt discontinuation: Stopping aspirin can lead to a rebound hypercoagulable state in high-risk patients 2
• One-size-fits-all approach: The decision to continue or discontinue aspirin must consider both cardiac and bleeding risks 1
• Starting aspirin day of surgery: Initiating aspirin therapy immediately before surgery provides no benefit and may increase bleeding risk 1
• Failing to restart aspirin: If aspirin is held, restart as soon as possible postoperatively 2

Dosing Considerations

• For patients on long-term aspirin therapy (up to 300 mg/day), maintain the same dosage throughout the perioperative period 1, 2
• Do not bridge antiplatelet agents with heparin (UFH or LMWH) or NSAIDs 1

The management of perioperative antiplatelet therapy ultimately requires consensus among treating clinicians and the patient, with careful consideration of both thrombotic and bleeding risks 1.