What is the recommended use of aspirin (acetylsalicylic acid) post-surgery?

Perioperative Management of Aspirin After Surgery

For most patients with coronary stents, aspirin should be maintained throughout the perioperative period unless there is a major risk of bleeding, and it should be resumed as soon as possible after surgery if it must be discontinued. 1

Risk Assessment for Aspirin Management Post-Surgery

• The decision to continue or discontinue aspirin perioperatively requires balancing two competing risks: hemorrhagic risk from surgery versus thrombotic risk from aspirin discontinuation 1
• A multidisciplinary team meeting involving the cardiologist, surgeon, anesthesiologist, and hemostasis specialist should make this decision based on individual patient factors 1
• The hemorrhagic risk of the procedure should be classified as major, intermediate, or minor 1
• The thrombotic risk should be assessed based on stent type, time since placement, and patient-specific factors 1, 2

Specific Recommendations Based on Clinical Scenario

For Patients with Drug-Eluting Coronary Stents:

• For procedures with minor bleeding risk: Maintain both aspirin and clopidogrel throughout the perioperative period 1
• For procedures with intermediate bleeding risk: Maintain aspirin but stop clopidogrel 5 days before surgery 1
• For procedures with major bleeding risk: Consider stopping both aspirin and clopidogrel if the stent was placed more than 6 months to 1 year ago 1
• If aspirin must be discontinued, it should be resumed as soon as possible after surgery 1, 2

For Patients Without Coronary Stents:

• For patients taking aspirin for primary prevention: Discontinue aspirin during the perioperative period, especially when there is a high risk of bleeding 3
• For patients with established cardiovascular disease but without coronary stents: Continue aspirin during the perioperative period unless undergoing surgery with high bleeding risk (e.g., neurosurgery, posterior eye segment surgery) 1, 3

Timing of Aspirin Resumption

• If aspirin was discontinued, it should be resumed as soon as possible after surgery when hemostasis is secured 1, 2
• For patients who were on dual antiplatelet therapy with clopidogrel, consider a loading dose of at least 300 mg of clopidogrel when resuming therapy 1
• Early resumption of aspirin is critical for patients with drug-eluting stents to prevent stent thrombosis 1, 2

Special Considerations

• For coronary artery bypass grafting (CABG), aspirin should be continued and administered early post-operatively to improve saphenous vein graft patency, despite a potential increase in blood loss 1, 4
• For high-risk endoscopic procedures, the risk of aspirin-induced bleeding may be higher in Eastern populations compared to Western populations 5
• For neurosurgery, intracranial procedures, or other surgeries with major bleeding risk, aspirin should be temporarily discontinued but resumed as soon as possible after bleeding is controlled 2

Monitoring and Follow-up

• Close monitoring for signs of stent thrombosis or recurrent bleeding is essential in the post-operative period 2
• For patients with drug-eluting stents, maintaining aspirin is particularly important within the first year after stent placement 1, 2
• The risk of stent thrombosis is highest when both aspirin and clopidogrel are discontinued in patients with recent stent placement 1

Common Pitfalls to Avoid

• Discontinuing aspirin in patients with recent coronary stent placement (within 30 days for bare-metal stents or 12 months for drug-eluting stents) significantly increases the risk of stent thrombosis and mortality 1
• Failing to resume aspirin as soon as possible after surgery in high-risk patients 1, 2
• Not considering the differential bleeding risk of various surgical procedures when making decisions about aspirin management 1
• Overlooking the need for a multidisciplinary approach to perioperative antiplatelet management 1