Aspirin Resumption After Blood Patch
Aspirin should be resumed within 24 hours after an epidural blood patch procedure, provided adequate hemostasis has been achieved and there are no ongoing bleeding concerns. 1
Timing of Resumption
The American College of Chest Physicians recommends resuming antiplatelet drugs ≤ 24 hours instead of > 24 hours after surgery or procedures in patients who require antiplatelet drug interruption for an elective procedure. 1 This guidance applies to blood patch procedures, which are considered intermediate bleeding risk interventions involving the neuraxial space.
Key Considerations for Blood Patch Specifically:
For high cardiovascular risk patients (those on aspirin for secondary prevention after MI, stroke, or with coronary stents), aspirin should be restarted as soon as hemostasis is confirmed, ideally within the first 24 hours post-procedure. 1, 2
For patients with recent coronary stents (within 6-12 weeks), the thrombotic risk of prolonged aspirin discontinuation is substantial, with stent thrombosis potentially occurring in as little as 7 days after discontinuation. 2, 3
Cardiovascular events after aspirin withdrawal typically occur between 7-10 days, with discontinuation associated with a 3-fold higher risk of major adverse cardiac events and up to a 10-fold increase in mortality in some populations. 3, 4
Risk Stratification Algorithm:
High Thrombotic Risk (recent stent, recent stroke/MI, acute coronary syndrome):
- Resume aspirin within 24 hours of blood patch if no active bleeding 1, 2
- Consider continuing aspirin throughout if bleeding risk is acceptable 5
Moderate Thrombotic Risk (stable coronary disease, prior stroke >3 months):
- Resume aspirin within 24 hours of blood patch 1
Low Thrombotic Risk (primary prevention only):
- May delay resumption 24-48 hours if bleeding concerns exist 5
- Consider whether aspirin needs to be restarted at all 5
Bleeding Risk Assessment:
If uncomplicated blood patch with good hemostasis: Resume aspirin within 24 hours 1, 5
If minor concerns about hemostasis or small hematoma: May delay 24-48 hours while monitoring 5
If significant bleeding complication or expanding hematoma: Withhold aspirin until bleeding is controlled, but reassess daily as prolonged discontinuation increases thrombotic risk 2, 5
Common Pitfalls to Avoid:
Unnecessarily prolonged discontinuation beyond 24-48 hours significantly increases thrombotic risk and mortality, particularly in patients on aspirin for secondary prevention. 2, 3
Failing to differentiate between primary and secondary prevention indications: Patients on aspirin for secondary prevention have a nearly 7-fold increase in risk for death or acute cardiovascular events when aspirin is discontinued. 2
Overlooking the rapid onset of thrombotic complications: The prothrombotic effect after aspirin withdrawal peaks at 7-10 days, making prompt resumption critical. 4, 6
In patients on dual antiplatelet therapy (DAPT): Never withhold both agents simultaneously; if aspirin must be held longer, continue the P2Y12 inhibitor to prevent stent thrombosis. 2, 3