How many days prior to surgery should Acetylsalicylic acid (aspirin) be stopped?

Aspirin Discontinuation Before Surgery

For most elective surgeries, stop aspirin ≤7 days (not the outdated 7-10 days) before the procedure, unless the patient has high cardiovascular risk, in which case aspirin should be continued perioperatively. 1, 2

Decision Algorithm

Step 1: Assess Cardiovascular Risk

High cardiovascular risk patients (continue aspirin):

• Prior myocardial infarction 3
• Prior stroke 3
• Coronary stents (especially drug-eluting stents) 2, 3
• Secondary prevention of cardiovascular disease 3

Low cardiovascular risk patients (stop aspirin ≤7 days):

• Primary prevention only 3
• No significant coronary artery disease 1

Step 2: Assess Surgical Bleeding Risk

High bleeding risk surgeries (stop aspirin 5-7 days preoperatively):

• Neurosurgery and intracranial procedures 2, 4
• Spinal surgery 5, 6
• Other closed-space surgeries where minor bleeding causes severe complications 2, 4

Low bleeding risk procedures (continue aspirin regardless of cardiovascular risk):

• Dental procedures 3
• Dermatologic procedures 3
• Cataract surgery 3

Moderate bleeding risk surgeries (individualize based on cardiovascular risk):

• Most abdominal operations 7
• Orthopedic procedures 4
• Vascular surgery 4

Key Evidence Points

The 2022 American College of Chest Physicians guidelines updated the recommendation from the traditional 7-10 day window to ≤7 days based on evidence showing no increased bleeding complications with shorter interruption periods. 1, 2 This change is critical because unnecessarily prolonged discontinuation increases thrombotic risk without additional bleeding benefit.

For patients with coronary stents: Aspirin should generally be continued throughout the perioperative period, as the thrombotic risk of stent thrombosis far outweighs bleeding concerns in most surgeries. 2, 3 If dual antiplatelet therapy is being used, aspirin should be continued while clopidogrel is stopped 5 days preoperatively (after appropriate stent maturation periods). 3

Evidence from major trials: The POISE-2 trial showed that perioperative aspirin continuation increased major bleeding (4.6% vs 3.8%) but did not reduce cardiovascular events, though this finding was complicated by high NSAID use (37% of patients). 1 Importantly, the bleeding increase was primarily in the aspirin initiation group, not the continuation group. 1

Resumption of Therapy

Resume aspirin within 24 hours after surgery once adequate hemostasis is achieved. 2, 3 The maximal antiplatelet effect occurs within minutes of taking aspirin, providing rapid cardiovascular protection. 1

Critical Pitfalls to Avoid

• Don't use the outdated 7-10 day discontinuation window when ≤7 days is sufficient for most patients, as this unnecessarily prolongs thrombotic risk. 2, 3

• Don't forget to ask about over-the-counter NSAIDs which have antiplatelet effects and can compound bleeding risk when combined with aspirin. 2, 3

• Don't discontinue aspirin in patients with recent coronary stents without cardiology consultation, as stent thrombosis can be catastrophic. 2, 3

• For spine surgery specifically: Given the devastating consequences of epidural hematoma causing paralysis, stopping aspirin 7-10 days preoperatively is prudent despite general guidelines suggesting shorter intervals. 5, 6