How long should Aspirin (Acetylsalicylic Acid) be held in an elderly patient with Coronary Artery Disease (CAD) and an acute patellar fracture managed conservatively?

Aspirin Management in Elderly Patients with Acute Patellar Fracture Treated Conservatively

Direct Answer

In an elderly patient with CAD and an acute patellar fracture managed conservatively (no surgery), aspirin should NOT be held and can be continued immediately without interruption. 1, 2

Rationale and Clinical Algorithm

Why Aspirin Should Not Be Stopped

• Aspirin provides critical cardiovascular protection that outweighs bleeding risk in this scenario. In patients with established CAD, aspirin reduces the combined risk of non-fatal MI, non-fatal stroke, or vascular death from 8.2% to 6.7% per year—preventing 15 serious vascular events per 1000 patients treated annually. 2

• The mortality risk from aspirin discontinuation substantially exceeds any bleeding risk from a conservatively managed patellar fracture. Aspirin interruption is associated with a three-fold increased risk of cardiovascular or cerebrovascular events, with 70% of these events occurring within 7-10 days of discontinuation. 2

• Conservative management (splinting) of a patellar fracture does not create a high bleeding risk scenario. Unlike surgical intervention, there is no operative site, no tissue dissection, and no procedural bleeding risk that would necessitate aspirin cessation. 3, 4

Evidence-Based Guidelines for Continuation

• ACC/AHA guidelines explicitly recommend continuing aspirin indefinitely in patients with established CAD unless a contraindication develops. 1 The guidelines emphasize that withdrawal of aspirin has been associated with recurrent episodes of acute coronary syndrome. 1

• The 2024 ESC guidelines for chronic coronary syndromes recommend aspirin 75-100 mg daily lifelong in patients with prior MI or established CAD. 1 This recommendation carries a Class I, Level A evidence rating—the highest level of recommendation. 1

• Aspirin should be continued throughout the perioperative period even for surgical procedures. 1 Since conservative management involves no surgery, there is even less justification for holding aspirin. 1

Optimal Dosing Strategy

• Use low-dose aspirin (75-100 mg daily) for maintenance therapy in CAD patients. 1, 2 This dose is as effective as higher doses for long-term cardiovascular protection while minimizing bleeding risk. 2

• Doses above 100 mg do not provide additional cardiovascular benefit but increase bleeding risk. 2 The ACC/AHA guidelines note that major bleeding rates increase from 2.0% with <100 mg to 4.0% with >200 mg daily. 1

Special Considerations for Patellar Fractures

• Patellar fractures in elderly patients are typically from low-energy mechanisms (82% from simple falls) and have good functional outcomes with conservative management when the extensor mechanism is intact. 3, 4 This low-energy mechanism does not create a high bleeding risk scenario that would justify aspirin cessation. 3

• Conservative management is appropriate for non-displaced fractures or those with intact extensor mechanism. 3 These patients can achieve excellent functional recovery (82% return to baseline mobility) without surgery. 3

Common Pitfalls to Avoid

• Do NOT reflexively hold aspirin based on the presence of a fracture alone. The indication for aspirin therapy (CAD) is more important than the theoretical bleeding risk from a conservatively managed fracture. 2, 5

• Do NOT restart aspirin at higher doses after any interruption. If aspirin was inappropriately held, restart at 75-100 mg daily, not at loading doses of 162-325 mg. 1, 2

• Do NOT combine aspirin discontinuation with other antiplatelet agents if the patient is on dual antiplatelet therapy. If DAPT modification is absolutely necessary for another reason, continue aspirin and withhold the P2Y12 inhibitor instead. 2

When Aspirin Might Need Modification

The only scenarios where aspirin management would require reconsideration in this patient are:

• Active life-threatening bleeding (which is not present in a conservatively managed patellar fracture). 2
• Severe thrombocytopenia (<50,000/μL) requiring individualized risk-benefit assessment. 2, 5
• Need for urgent high-risk surgery (not applicable here as management is conservative). 1

Monitoring Recommendations

• Continue aspirin 75-100 mg daily indefinitely as long as CAD indication persists. 1
• Reassess for any signs of bleeding complications during fracture healing, though risk is minimal with conservative management. 2
• Ensure patient understands the critical importance of not self-discontinuing aspirin, as withdrawal increases cardiovascular event risk. 1, 2