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

How Long to Stop Aspirin Before Surgery

For most elective non-cardiac surgeries requiring aspirin interruption, stop aspirin ≤7 days (not the traditional 7-10 days) before the procedure. 1

General Timing Recommendations

The American College of Chest Physicians (2022) recommends stopping aspirin ≤7 days instead of 7-10 days before elective non-cardiac surgery when interruption is necessary. 1 This represents an evolution from older guidelines that recommended 7-10 day interruption. 1

Key Timing Points:

• Standard interruption: ≤7 days preoperatively for most surgeries requiring aspirin cessation 1
• High bleeding-risk surgeries: 5-7 days preoperatively for procedures like neurosurgery, intracranial surgery, or other closed-space surgeries where even minor bleeding causes severe complications 2, 3, 4
• Resumption: 12-24 hours postoperatively when adequate hemostasis is achieved 1, 2, 3

Decision Framework: Continue vs. Stop

The critical decision is whether to stop aspirin at all, not just when to stop it. This depends on balancing thrombotic risk against bleeding risk.

When to CONTINUE Aspirin (Do Not Stop):

For patients at high cardiovascular risk undergoing intermediate bleeding-risk surgery, continuing aspirin perioperatively is often preferred. 1, 2 Specifically:

• Patients with coronary stents (especially drug-eluting stents): Continue aspirin throughout the perioperative period 1, 2, 5
• Recent acute coronary syndrome or myocardial infarction: Continue aspirin 1, 2
• Most cardiovascular, vascular, and orthopedic surgeries: Aspirin continuation is safe and does not increase clinically significant bleeding 4
• Cardiac surgery (CABG): Despite increased blood loss, perioperative aspirin improves graft patency and does not increase mortality 1, 2

When to STOP Aspirin:

Stop aspirin when the bleeding risk of the specific surgery outweighs the thrombotic risk. 1, 2 High bleeding-risk procedures include:

• Neurosurgery and intracranial procedures: Stop 5-7 days preoperatively 2, 3, 4
• Spinal surgery: Stop >7-10 days preoperatively 6
• Transurethral prostatectomy: May require interruption 1
• Procedures in closed anatomical spaces where minor bleeding causes major complications 2

Surgery-Specific Considerations

Cardiac Surgery (CABG):

• Traditional practice: Stop 4-5 days before surgery 1
• Evidence shows: Continuing aspirin improves outcomes despite increased blood loss 1
• ACC/AHA recommendation: Aspirin should be administered within 48 hours of operation and continued indefinitely 1

Non-Cardiac Surgery:

• POISE-2 trial findings: Perioperative aspirin continuation did not reduce cardiovascular events but increased major bleeding (4.6% vs 3.8%) 1
• However: The bleeding increase was primarily in the aspirin initiation group, not the continuation group 1
• Practical implication: For patients already on aspirin for secondary prevention, continuation may be safer than stopping and restarting 7

Pancreatic Surgery:

• Recent evidence: Continuation of aspirin through pancreatic resection showed no increased bleeding, transfusion requirements, or complications 8

Important Caveats and Pitfalls

Common Errors:

• Stopping aspirin for too long (10 days) when 7 days or less is sufficient for most procedures 2, 3
• Failing to account for over-the-counter NSAIDs that patients may not report, which have antiplatelet effects 2, 5
• Stopping aspirin in high-risk cardiovascular patients without adequate risk-benefit analysis 1, 2

Special Populations:

Patients with drug-eluting stents:

• Ideally delay elective surgery until 12 months after stent placement 2, 5
• If surgery cannot be delayed: Continue aspirin and stop P2Y12 inhibitor (clopidogrel) 5 days before surgery 3, 5
• Never stop both antiplatelet agents simultaneously in stent patients unless absolutely necessary 1, 2

Patients on dual antiplatelet therapy:

• If thienopyridine must be stopped: Continue aspirin and restart the P2Y12 inhibitor as soon as possible postoperatively 1, 2
• Clopidogrel: Stop 5 days before surgery 5, 6
• Prasugrel: Stop 7 days before surgery 5
• Ticagrelor: Stop 3-5 days before surgery 1, 5

Physiologic Rationale

Aspirin irreversibly inhibits platelet cyclooxygenase, affecting platelets for their entire 7-10 day lifespan. 3, 4 However, adequate hemostasis does not require 100% platelet function recovery—approximately 20-30% of normal platelet function is sufficient for hemostasis, which occurs within 3-5 days as new platelets are produced. 3, 4 This explains why shorter interruption periods (≤7 days) are now recommended rather than waiting for complete platelet turnover.

Risk-Benefit Analysis

The STRATAGEM trial (randomized, placebo-controlled) found no significant difference in major thrombotic or bleeding events between aspirin continuation versus interruption in patients undergoing elective non-cardiac surgery. 7 This suggests that for many intermediate-risk procedures, the decision may be equipoise, and continuation may be preferable to avoid the thrombotic risk of interruption.

Aspirin continuation increases the frequency of procedural bleeding (relative risk 1.5) but does not increase the severity of bleeding complications or perioperative mortality in most surgeries. 1, 2