When should aspirin (acetylsalicylic acid) be stopped before non-cardiac surgery to minimize perioperative bleeding risk?

Perioperative Aspirin Management for Non-Cardiac Surgery

For patients undergoing elective non-cardiac surgery who require aspirin interruption, aspirin should be stopped ≤7 days before surgery rather than the traditional 7-10 days. 1, 2

General Recommendations

• The American College of Chest Physicians (ACCP) provides a conditional recommendation (with very low certainty of evidence) to stop aspirin ≤7 days before elective non-cardiac surgery rather than 7-10 days when interruption is required 1
• This recommendation may be modified based on individual circumstances, particularly considering surgery-related bleeding risk 1
• The decision to continue or discontinue aspirin should be determined by consensus between treating clinicians and the patient, weighing thrombotic risks against bleeding risks 1

Risk Stratification Approach

High Thrombotic Risk Patients (Continue Aspirin)

• Patients with recent coronary stents, especially during the first 4-6 weeks after bare-metal stent (BMS) or drug-eluting stent (DES) implantation 1
• Patients with drug-eluting stents (DES) where aspirin should be continued perioperatively whenever possible 2
• If dual antiplatelet therapy is required but P2Y12 inhibitors (clopidogrel, ticagrelor, prasugrel) must be discontinued, continue aspirin throughout the perioperative period 1, 2

High Bleeding Risk Procedures (Discontinue Aspirin)

• Neurosurgery, spinal surgery, or other closed-space procedures where even minor bleeding can lead to severe complications 2
• For these high-bleeding risk surgeries, aspirin should be withdrawn 5-7 days preoperatively 2
• Elective surgery should be delayed until at least 30 days after BMS placement and 12 months after DES placement if aspirin must be discontinued 1, 2

Evidence on Bleeding vs. Thrombotic Risk

• The POISE-2 trial (10,010 patients) showed that perioperative aspirin did not reduce the risk of death or nonfatal myocardial infarction (7.0% vs 7.1%) but increased the risk of major bleeding (4.6% vs 3.8%) 3
• However, POISE-2 excluded patients within 6 weeks of BMS placement or within 1 year of DES placement, limiting its applicability to high-risk cardiac patients 1
• A smaller randomized trial (220 patients) found that perioperative aspirin reduced major adverse cardiac events (1.8% vs 9.0%) without significantly increasing bleeding complications in high-risk patients 4
• A systematic review and meta-analysis found no difference in major adverse cardiac events with planned discontinuation of aspirin, and decreased risk of perioperative bleeding with early discontinuation 5

Resumption of Aspirin Therapy

• For patients with coronary stents requiring discontinuation of P2Y12 inhibitors, aspirin should be continued and the P2Y12 inhibitor restarted as soon as possible after surgery 1
• Aspirin should be resumed within 24 hours after surgery when adequate hemostasis has been achieved 2
• For high thrombotic risk patients, aspirin should be restarted as soon as possible, ideally within the first 24 hours postoperatively 2

Common Pitfalls and Considerations

• Many clinicians discontinue aspirin for longer than necessary (10 days) when ≤7 days is typically sufficient 2
• Patients may not report over-the-counter use of NSAIDs with antiplatelet effects, requiring thorough medication reconciliation 2
• Bleeding risk significantly increases when multiple antiplatelet or anticoagulant medications are combined 2
• For patients taking aspirin for primary prevention without established cardiovascular disease, discontinuation throughout the perioperative period is likely appropriate, especially with high bleeding risk procedures 6

Special Considerations

• If thienopyridines must be discontinued before major surgery, aspirin should be continued if possible and the thienopyridine restarted as soon as possible 1, 2
• For cardiac surgery, perioperative aspirin use may increase blood loss but does not increase mortality and is associated with improved bypass graft patency 2
• Patients with coronary stents undergoing non-cardiac surgery should generally continue aspirin throughout the perioperative period unless undergoing high-risk bleeding procedures 2