Perioperative Management of Aspirin Before Surgery
Aspirin should be stopped ≤7 days before elective surgery when bleeding risk is significant, but continued if the thrombotic risk outweighs bleeding concerns. 1
General Recommendations for Aspirin Discontinuation
- For most elective surgeries, aspirin should be discontinued ≤7 days before surgery rather than the traditional 7-10 days 1, 2
- The irreversible effect of aspirin on platelets lasts for the entire lifespan of platelets (7-10 days), but complete discontinuation is often unnecessary 3
- For patients at high risk of thrombotic events, aspirin should be continued perioperatively if the bleeding risk is manageable 1
- The decision to continue or discontinue aspirin should be based on weighing thrombotic risk against surgical bleeding risk 1, 4
Surgery-Specific Considerations
High Bleeding Risk Procedures
- For neurosurgery and other closed-space surgeries where even minor bleeding can lead to severe complications, aspirin should be withdrawn 5-7 days preoperatively 1, 3
- For high bleeding risk procedures in patients with coronary stents, consider stopping aspirin only if absolutely necessary, and restart as soon as possible 1, 2
Low-to-Moderate Bleeding Risk Procedures
- For cardiovascular, vascular, and orthopedic surgeries, aspirin continuation is often safe as these procedures typically don't show clinically relevant bleeding complications with aspirin 3
- For patients with coronary stents undergoing non-cardiac surgery, aspirin should generally be continued throughout the perioperative period 1, 2
Special Patient Populations
Patients with Coronary Stents
- For patients with drug-eluting stents (DES), aspirin should be continued perioperatively whenever possible 1
- If thienopyridines (e.g., clopidogrel) must be discontinued before major surgery, aspirin should be continued and the thienopyridine restarted as soon as possible 1
- Elective surgery should be delayed until at least 30 days after bare-metal stent (BMS) placement and 12 months after DES placement 1
Patients with Other Cardiovascular Disease
- For patients with established cardiovascular disease but without coronary stents, aspirin should likely be continued during perioperative period unless undergoing closed-space surgery 4
- For patients taking aspirin for primary prevention only, discontinuation during the perioperative period is appropriate, especially with high bleeding risk 4
Resumption of Aspirin Therapy
- Aspirin should be resumed within 24 hours after surgery when adequate hemostasis has been achieved 2
- For patients at high risk of thrombotic events, aspirin should be restarted as soon as possible, ideally within the first 24 hours postoperatively 1, 2
Risks and Benefits Analysis
- Continuing aspirin may increase the frequency of procedural bleeding (relative risk 1.5) but typically does not increase the severity of bleeding complications or perioperative mortality 1
- The STRATAGEM trial found no significant difference in major thrombotic or bleeding events between preoperative maintenance or interruption of aspirin in patients undergoing elective non-cardiac surgery 5
- For cardiac surgery, perioperative aspirin use may increase blood loss but does not increase mortality and is associated with improved bypass graft patency 1, 6
Common Pitfalls and Caveats
- Many clinicians discontinue aspirin for longer than necessary (10 days) when 7 days or less is typically sufficient 1, 3
- Patients may not report over-the-counter use of NSAIDs with antiplatelet effects, so thorough medication reconciliation is essential 2
- Bleeding risk is significantly increased when multiple antiplatelet or anticoagulant medications are combined 2
- For patients with coagulation disorders, aspirin should always be withdrawn prior to surgery 3
By following these evidence-based recommendations, clinicians can optimize the perioperative management of aspirin to balance the risks of thrombotic events against surgical bleeding complications.