When should aspirin (acetylsalicylic acid) be stopped before a procedure to minimize bleeding risk?

Aspirin Stoppage Prior to Procedures

For most elective non-cardiac surgeries, aspirin should be stopped 3-5 days before the procedure, with 5 days being the safest interval for high-bleeding-risk surgeries. 1, 2

General Timing Recommendations

Standard Surgical Procedures

• Stop aspirin 5-7 days before surgery for procedures with high bleeding risk, though the American College of Chest Physicians specifically recommends ≤7 days rather than 7-10 days to minimize thrombotic risk 1
• Stop aspirin 3-5 days before surgery for most elective procedures, as platelet function improves significantly within this timeframe and complete recovery is not necessary for adequate hemostasis 1, 2, 3
• The irreversible effect of aspirin on platelets lasts 7-10 days (full platelet lifespan), but only 20% of circulating platelets need normal function for adequate hemostasis 4, 5

High-Bleeding-Risk Surgeries

• Stop aspirin 5 days before neurosurgery, intracranial procedures, spinal surgery in the medullary canal, or posterior chamber eye surgery where bleeding occurs in closed spaces 2, 4, 5
• For coronary artery bypass grafting (CABG), stop aspirin 5 days before surgery in low-risk patients, though continuation may be considered in high-risk patients 2

Special Clinical Scenarios

Patients with Coronary Stents

• Continue aspirin perioperatively in patients with recent stent placement who require urgent surgery 1, 6
• Surgery should be deferred for at least 6 weeks after bare-metal stent placement and 6 months after drug-eluting stent placement 1
• If surgery cannot be delayed beyond these intervals, continue aspirin and stop only the P2Y12 inhibitor 5-7 days before the procedure 1
• The risk of stent thrombosis when both antiplatelet drugs are stopped is catastrophic (median time to thrombosis: 7 days), versus 122 days when one agent is continued 1

Dual Antiplatelet Therapy Management

• Continue aspirin while stopping the P2Y12 inhibitor for high-risk endoscopic or surgical procedures 1
• Stop clopidogrel 5-7 days before surgery 1, 6
• Stop prasugrel 7-10 days before surgery 6
• Stop ticagrelor 3-5 days before surgery (shorter duration due to reversible binding) 1, 6

Dental Procedures

• Continue aspirin without interruption for all dental procedures, including extractions 7
• The American College of Cardiology/American Heart Association explicitly states there is no indication to interrupt aspirin for dental procedures 7
• Oral bleeding is easily controlled with local hemostatic measures (absorbable gelatin sponges, sutures, compression) 7
• The cardiovascular risk of stopping aspirin substantially outweighs the minimal and manageable bleeding risk 7

Low-Bleeding-Risk Procedures

• Continue aspirin for most cardiovascular, vascular, and orthopedic surgeries, as well as epidural anesthesia 5
• Studies show no clinically relevant bleeding complications in these settings, only minor increases in non-clinically significant blood loss 5

Resumption of Aspirin

• Resume aspirin 12-24 hours after surgery (evening of surgery or next morning) when adequate hemostasis is achieved 1, 2
• In patients at risk for coronary stent thrombosis, resume P2Y12 inhibitors once adequate hemostasis is achieved 1

Critical Pitfalls to Avoid

Do Not Routinely Stop Aspirin

• The thrombotic risk of stopping aspirin often exceeds the bleeding risk, particularly in patients with cardiovascular disease 7, 4, 5
• For patients on aspirin for secondary prevention, the yearly thrombotic risk without antiplatelet therapy is 3.11% versus 0.34% for primary prevention (10-fold higher) 1

Do Not Confuse Antiplatelet Agents

• Avoid instructing patients to stop all "blood thinners" without distinguishing between anticoagulants and antiplatelet agents 7
• P2Y12 inhibitors require longer discontinuation periods than aspirin due to greater potency 1

Do Not Use Heparin Bridging for Aspirin

• Heparin or low-molecular-weight heparin does not protect against coronary artery or stent thrombosis and may increase bleeding risk 4

Do Not Delay Necessary Procedures

• Many procedures can be performed safely without stopping aspirin, particularly dental work and low-bleeding-risk surgeries 7, 5

Algorithm for Decision-Making

1. Identify procedure bleeding risk:

   • High-risk (neurosurgery, spinal, intracranial, posterior eye chamber): Stop aspirin 5 days before 2, 5
   • Moderate-risk (most surgeries): Stop aspirin 3-5 days before 1, 2
   • Low-risk (dental, minor procedures): Continue aspirin 7, 5

2. Assess thrombotic risk:

   • Recent stent (<6 months DES, <6 weeks BMS): Continue aspirin, stop only P2Y12 inhibitor 1
   • Secondary cardiovascular prevention: Strongly consider continuing aspirin 1, 5
   • Primary prevention only: May stop aspirin if high bleeding risk 1

3. Coordinate with cardiology for patients with coronary stents or recent acute coronary syndrome before stopping any antiplatelet therapy 1, 6