When should aspirin (acetylsalicylic acid) be held before a surgical procedure?

When to Hold Aspirin Before Surgery

For most elective non-cardiac surgeries, aspirin should be stopped ≤7 days (not the traditional 7-10 days) before the procedure when interruption is required, though continuation is preferred for patients on secondary cardiovascular prevention unless the surgery carries high bleeding risk. 1

Decision Framework: Continue vs. Hold Aspirin

Continue Aspirin Throughout Surgery (Preferred Strategy)

• Secondary cardiovascular prevention patients (history of MI, stroke, peripheral artery disease) undergoing most surgeries 1, 2
• Coronary artery bypass grafting (CABG): Continue aspirin perioperatively—improves graft patency and reduces mortality without increasing mortality from bleeding 1
• Carotid endarterectomy and vascular surgery: Continue aspirin—improves outcomes and graft patency 1
• Patients with coronary stents: Aspirin must be continued throughout the perioperative period whenever possible 1, 2

Hold Aspirin 5-7 Days Preoperatively (High Bleeding Risk)

• Neurosurgery and intracranial procedures: Stop 5-7 days before surgery—even minor bleeding can cause catastrophic complications (epidural hematoma, paralysis) 1, 3, 4
• Spinal surgery: Stop 7-10 days preoperatively to avoid epidural hematoma and irreversible paralysis 4
• Closed-space surgeries where bleeding cannot be easily controlled 2, 5
• Transurethral prostatectomy: May require discontinuation due to increased bleeding risk 1

Discontinue Aspirin Immediately

• Primary prevention only (no established cardiovascular disease): Stop aspirin preoperatively—risks outweigh benefits 1, 5

Timing of Aspirin Discontinuation

The 2022 American College of Chest Physicians guidelines recommend stopping aspirin ≤7 days (not 7-10 days) before surgery when interruption is necessary. 1 This represents a shift from older recommendations:

• Standard timing: Stop 5-7 days preoperatively for most surgeries requiring interruption 1, 6, 2
• High bleeding risk surgeries: Stop 7 days (or up to 10 days for spine surgery) 1, 4
• Rationale: While aspirin irreversibly inhibits platelets for 7-10 days, full platelet recovery is not necessary for adequate hemostasis—3-5 days allows sufficient new platelet generation 6, 3

Special Populations: Patients with Coronary Stents

This is the highest-risk scenario requiring careful management:

Timing Restrictions

• Bare-metal stents (BMS): Avoid elective surgery within 30 days of placement 1, 2
• Drug-eluting stents (DES): Avoid elective surgery within 12 months of placement 1, 2

If Surgery Cannot Be Delayed

• Continue aspirin perioperatively if at all possible 1, 2
• If dual antiplatelet therapy (DAPT) must be interrupted:
  • Stop thienopyridine (clopidogrel/ticagrelor) 5 days before surgery 1
  • Continue aspirin throughout 1, 2
  • Restart thienopyridine within 5 days postoperatively, ideally within 24 hours 1
• Median time to stent thrombosis: 7 days if both agents stopped, but 122 days if only thienopyridine stopped while maintaining aspirin 1

Only Stop Both Agents When

• Bleeding risk clearly outweighs thrombotic risk 1
• Stop no sooner than 5 days preoperatively 1
• Restart both agents within 5 days postoperatively 1

Resuming Aspirin Postoperatively

Restart aspirin within 12-24 hours after surgery once adequate hemostasis is achieved. 6, 2

• For high thrombotic risk patients (stents, recent MI): Resume as soon as possible, ideally within 24 hours 2
• For CABG patients: Resume within 48 hours postoperatively 1

Bleeding Risk vs. Thrombotic Risk

Bleeding Risk with Continued Aspirin

• Increases frequency of procedural bleeding (relative risk 1.5) 1, 2
• Does not increase severity of bleeding complications or perioperative mortality in most surgeries 1, 2
• In CABG: Increases blood loss and reoperation rate but improves graft patency and does not increase mortality 1, 2

Thrombotic Risk with Aspirin Discontinuation

• 6.1% incidence of thrombotic events in patients with peripheral artery disease who stopped aspirin 1
• Perioperative period is inherently prothrombotic due to surgical inflammation 1
• Risk is highest in patients with recent stents or acute coronary syndromes 1

Common Pitfalls to Avoid

• Stopping aspirin for 10 days unnecessarily: The 2022 guidelines support ≤7 days for most surgeries 1, 2
• Stopping aspirin in stent patients: This dramatically increases stent thrombosis risk—continue aspirin whenever possible 1, 2
• Failing to restart aspirin promptly: Delay increases thrombotic risk—resume within 24 hours when hemostasis permits 6, 2
• Using heparin bridging with aspirin: This increases bleeding risk without clear benefit 6
• Missing over-the-counter NSAID use: Thorough medication reconciliation is essential 2

Algorithm Summary

1. Determine indication: Primary vs. secondary prevention
2. Assess surgery type: High bleeding risk (neurosurgery, spine) vs. standard risk
3. Check for coronary stents: If present, continue aspirin unless absolutely contraindicated
4. If holding aspirin:
   • Stop 5-7 days preoperatively (7-10 days for spine/neurosurgery)
   • Resume within 24 hours postoperatively
5. If continuing aspirin: Accept modest increase in bleeding frequency but not severity