Aspirin Resumption After Ketorolac Injection
Aspirin should be restarted within 24 hours after ketorolac discontinuation in patients with high thrombotic risk (recent coronary stents, stroke history, or acute coronary syndrome), and immediately when hemostasis is adequate in these high-risk patients. 1
Risk-Stratified Approach to Aspirin Resumption
High Thrombotic Risk Patients
For patients with recent coronary stents, stroke history, or acute coronary syndrome, restart aspirin immediately after ketorolac cessation to prevent a 7-fold increase in mortality risk. 1 The median time to stent thrombosis is only 7 days when antiplatelet therapy is interrupted, making prompt resumption critical. 1
- The American Heart Association recommends restarting aspirin immediately after ketorolac discontinuation in high-risk patients. 1
- The European Society of Cardiology guidelines suggest restarting aspirin within 24 hours after ketorolac cessation for high-risk patients. 1
- In patients treated with thrombolysis (tPA), aspirin should be delayed until after the 24-hour post-thrombolysis scan has excluded intracranial hemorrhage. 2
Moderate Thrombotic Risk Patients
For patients with stable coronary artery disease, aspirin can be restarted within 1-2 days after ketorolac cessation, ensuring hemostasis is adequate before resumption. 1, 3
Dual Antiplatelet Therapy (DAPT) Patients
If a patient was on dual antiplatelet therapy, aspirin should be restarted first (immediately to within 24 hours), and the P2Y12 inhibitor should be resumed within 2-5 days maximum after hemostasis. 1, 3
- Never discontinue both antiplatelet agents simultaneously due to the extreme risk of stent thrombosis. 1
- Continue DAPT in patients undergoing urgent procedures during the first 4-6 weeks after bare-metal stent (BMS) or drug-eluting stent (DES) implantation, unless bleeding risk outweighs stent thrombosis prevention benefit. 2
- Restart the P2Y12 platelet receptor-inhibitor as soon as possible after surgery in patients with stents. 2
Perioperative Aspirin Management Context
Standard Perioperative Guidelines
Aspirin should be discontinued one week prior to surgical procedures and restarted 24 hours after surgery or when considered acceptable depending on bleeding risk. 2
- In patients requiring surgery, aspirin may be continued when the risk of increased cardiac events outweighs the risk of increased bleeding. 2
- For most elective procedures, aspirin can be safely restarted within 24 hours if there are no concerns about bleeding. 3
Post-Procedure Monitoring
If there were complications during the procedure or concerns about hemostasis, consider delaying aspirin resumption for 24-48 hours while monitoring for bleeding. 3
Contraindications to Immediate Aspirin Resumption
Do not restart aspirin immediately if any of the following are present:
- Active uncontrolled gastrointestinal bleeding 1
- Intracranial hemorrhage 1
- Major surgical bleeding not yet controlled 1
- Post-operative bleeding complications (withhold until bleeding is controlled) 3
Ketorolac-Specific Considerations
Ketorolac produces modest prolongation of bleeding time (from 4.9 to 7.8 minutes) but does not affect prothrombin time or partial thromboplastin time. 4 This reversible antiplatelet effect is substantially less than aspirin's effect. 5
- Ketorolac's platelet inhibition is reversible, unlike aspirin's irreversible inhibition that lasts 7-10 days. 6, 4
- The bleeding time effects of ketorolac are dose-dependent and resolve after discontinuation. 7, 4
- Ketorolac at standard doses (15-30 mg IV) has minimal impact on platelet function compared to aspirin or higher-dose NSAIDs. 5, 8
Common Pitfalls to Avoid
Never delay aspirin resumption beyond 24 hours in high-risk patients without a compelling bleeding contraindication, as this dramatically increases thrombotic risk. 1 The risk of stent thrombosis or recurrent stroke far outweighs the modest bleeding risk from early aspirin resumption in most clinical scenarios. 1