Aspirin Management for Hip Replacement Surgery
For patients undergoing elective hip replacement, aspirin 81 mg should generally be continued throughout the perioperative period rather than being held, as continuation does not significantly increase bleeding risk while providing important cardiovascular and VTE protection. 1, 2, 3
Primary Recommendation: Continue Aspirin
The 2022 American College of Chest Physicians guidelines recommend continuing aspirin perioperatively for patients undergoing hip replacement, particularly those taking it for cardiovascular indications. 1
The landmark PEP trial of 17,444 patients undergoing hip fracture repair or hip/knee replacement demonstrated that aspirin reduced VTE risk (RR 0.71; 95% CI: 0.54-0.94) with only a modest increase in major bleeding (2.9% vs 2.4%; P = 0.04). 1
Real-world data from 757 consecutive hip replacement patients showed that continuing aspirin did not increase perioperative bleeding, complications, readmissions, or mortality compared to patients not on aspirin. 4
If Aspirin Must Be Held (High Bleeding Risk Scenarios)
If you determine aspirin interruption is necessary due to exceptionally high bleeding risk, stop aspirin ≤7 days (not 7-10 days) before surgery. 1, 2, 3
Timing of Interruption:
The updated 2022 ACCP guidelines specifically recommend stopping aspirin ≤7 days (meaning 7 days or less) rather than the outdated 7-10 day window. 1
Since aspirin irreversibly inhibits platelet function, 7 days allows for adequate platelet turnover to restore hemostasis. 1
For hip replacement specifically (not a closed-space surgery like neurosurgery), 5-7 days of interruption is sufficient if holding is deemed necessary. 2
When to Consider Holding:
Only consider interruption in patients at very low cardiovascular risk who are taking aspirin for primary prevention (not secondary prevention). 2, 3
The decision should weigh the patient's thrombotic risk (history of MI, stroke, coronary stents) against surgical bleeding risk. 1, 2
Resumption of Aspirin Post-Surgery
Resume aspirin within 24 hours after surgery once adequate hemostasis is achieved. 2, 3
Maximal antiplatelet effect occurs within minutes of taking aspirin, providing immediate cardiovascular and VTE protection. 1
For patients with coronary stents or high cardiovascular risk, restart as soon as possible postoperatively, ideally within the first 24 hours. 2, 3
Evidence Supporting Continuation
Cardiovascular Protection:
A study of 1,549 hip replacement patients using aspirin as thromboprophylaxis showed zero 30-day and 90-day mortality, with cardiovascular deaths dropping from 0.75% to zero compared to no prophylaxis. 5
The POISE-2 trial showed that aspirin continuation (not initiation) did not increase major bleeding significantly (4.6% vs 4.1%; HR 1.11; 95% CI: 0.84-1.48). 1
Bleeding Risk is Manageable:
Historical data from 129 hip replacement patients showed that aspirin-induced bleeding time prolongation did not translate to increased perioperative blood loss in 6 of 8 surgical subsets. 6
Continuing aspirin increases the frequency but not the severity of bleeding complications. 2
Common Pitfalls to Avoid
Do not hold aspirin for 10 days—this is outdated practice that unnecessarily increases thrombotic risk without additional bleeding benefit. 2, 3
Do not assume all patients need aspirin held—hip replacement is not a closed-space surgery where minor bleeding causes catastrophic complications. 2
Ensure thorough medication reconciliation, as patients may not report over-the-counter NSAIDs that compound antiplatelet effects. 2, 3
For patients on dual antiplatelet therapy (aspirin + P2Y12 inhibitor), continue aspirin but hold the P2Y12 inhibitor (clopidogrel 5 days, ticagrelor 3-5 days, prasugrel 7 days before surgery). 3