Preoperative Aspirin Management
For most noncardiac surgeries, aspirin should be stopped 3 days before the procedure, except for high-bleeding-risk surgeries (intracranial neurosurgery, posterior chamber eye surgery, medullary canal procedures) where it should be stopped 5 days preoperatively. 1, 2
Standard Timing for Aspirin Discontinuation
General noncardiac surgery:
- Last aspirin dose on Day -3 (3 days before surgery) 1, 2
- This timing allows sufficient platelet function recovery for adequate hemostasis without requiring complete platelet turnover 2
- Aspirin's irreversible platelet inhibition lasts 7-10 days, but full recovery is unnecessary for surgical hemostasis 2, 3
High-bleeding-risk procedures:
- Last aspirin dose on Day -5 (5 days before surgery) for intracranial neurosurgery 1
- Also applies to posterior chamber eye surgery and procedures in confined spaces 1
- Prostatectomy may warrant 5-day discontinuation 1
Critical Exceptions: When to Continue Aspirin
Do NOT stop aspirin for:
- Cardiac surgery (CABG): Continue aspirin through surgery and restart within 48 hours postoperatively 1
- Carotid endarterectomy: Continue aspirin perioperatively 1
- Peripheral vascular surgery: Continue aspirin for improved graft patency 1
- Very low bleeding-risk procedures: Continue aspirin without interruption 1
Patients with coronary stents:
- Continue aspirin throughout the perioperative period unless performing closed-space surgery 1, 4
- If dual antiplatelet therapy must be interrupted, maintain aspirin and stop only the P2Y12 inhibitor 1, 2
- Surgery should ideally be delayed until 12 months after drug-eluting stent placement 1
Risk Stratification Algorithm
High thrombotic risk (continue aspirin):
- Recent coronary stent placement (especially <12 months) 1
- Recent acute coronary syndrome 1
- Recent stroke or TIA 1
- Established coronary, cerebrovascular, or peripheral arterial disease undergoing low-to-moderate bleeding risk surgery 1
Low thrombotic risk (safe to discontinue):
- Primary cardiovascular prevention only 1, 4
- No recent cardiovascular events 1
- Low cardiovascular risk profile 1
Postoperative Resumption
- Resume aspirin 12-24 hours after surgery once adequate hemostasis is achieved 2, 5
- Earlier resumption (within 48 hours) is standard for cardiac surgery 1
Critical Pitfalls to Avoid
Do not bridge with heparin:
- Bridging aspirin with heparin (UFH or LMWH) increases bleeding risk without clear benefit 1, 5
- No evidence supports bridging for aspirin discontinuation 1
Do not reduce aspirin dose preoperatively:
- Patients on long-term aspirin up to 300 mg/day should maintain their usual dose until discontinuation 1
- Doses ≤100 mg/day may not significantly increase bleeding in some surgeries 6
Consult cardiology before stopping aspirin in:
- Any patient with coronary stents 1, 5
- Recent acute coronary syndrome (within 6 weeks) 5
- Recent cerebrovascular events 5
Evidence Quality Considerations
The 2025 Association of Anaesthetists guidelines provide the most current recommendations, supporting 5-day discontinuation for high-risk procedures 1. The French Working Group (2018) offers more granular timing with 3-day discontinuation for standard procedures and 5-day for neurosurgery 1. Earlier ACC/AHA guidelines (2007) suggested aspirin continuation for most noncardiac surgeries, but this predates more recent bleeding risk data 1. The STRATAGEM trial (2011) showed no difference in outcomes between continuation and interruption, but was underpowered and terminated early 7.
The balance favors 3-day discontinuation for standard procedures and 5-day for high-bleeding-risk surgeries, with continuation only when thrombotic risk clearly exceeds bleeding risk. 1, 2