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

Perioperative Management of Aspirin

For patients at low risk for cardiovascular events, aspirin should be stopped 7 to 10 days before surgery, while patients at moderate to high cardiovascular risk should continue aspirin throughout the perioperative period. 1, 2

Timing of Aspirin Discontinuation Based on Cardiovascular Risk

Low Cardiovascular Risk Patients

• Stop aspirin 7 to 10 days before surgery 1
• This allows adequate time for new platelets to be produced, as aspirin irreversibly inhibits platelet function for the entire lifespan of the platelet (7-10 days) 3

Moderate to High Cardiovascular Risk Patients

• Continue aspirin throughout the perioperative period 1, 2
• This includes patients with:
  • Secondary prevention of cardiovascular disease
  • Recent coronary stent placement
  • History of myocardial infarction
  • High risk for thrombotic events

Special Surgical Considerations

• For minor procedures (dental, dermatologic, cataract surgery), continue aspirin regardless of cardiovascular risk 1, 2
• For coronary artery bypass grafting (CABG), continue aspirin throughout the perioperative period 1
• For neurosurgery or procedures where bleeding in a closed space could be catastrophic, consider stopping aspirin even in high-risk patients 4

Stent-Specific Recommendations

• For patients with bare-metal stents: defer elective surgery for at least 6 weeks after placement 1
• For patients with drug-eluting stents: defer elective surgery for at least 6 months after placement 1
• If surgery cannot be delayed within these timeframes, continue dual antiplatelet therapy throughout the perioperative period 1, 2

Bleeding Risk Considerations

While continuing aspirin may increase chest tube drainage and blood product requirements in some surgeries 5, the risk of coronary thrombosis after aspirin withdrawal is significantly higher than the risk of surgical bleeding if continued 4. Recent evidence suggests that the traditional recommendation to stop aspirin 7-10 days before all surgeries is not supported by clinical data 3.

Common Pitfalls to Avoid

1. Premature discontinuation: Stopping antiplatelet therapy prematurely carries a 10% risk of vascular events 6
2. One-size-fits-all approach: Not considering the individual's cardiovascular risk when deciding whether to continue or stop aspirin
3. Failure to consult: Not involving cardiology before discontinuing antiplatelet therapy in high-risk patients 2
4. Inadequate monitoring: Not checking for adequate hemostasis before resuming aspirin postoperatively

Remember that aspirin should be restarted within 24-48 hours after surgery once adequate hemostasis is achieved 2. For patients on dual antiplatelet therapy, clopidogrel should be stopped 5 days before surgery while maintaining aspirin when possible 2, 7.