Should aspirin be stopped before surgery?

Should Aspirin (Ecospirin) Be Stopped Before Surgery?

For most elective surgeries, aspirin should be discontinued 5-7 days before the procedure, but must be continued perioperatively in patients at high cardiovascular risk (recent MI, coronary stents, or high thrombotic risk) unless the surgery involves a closed space where even minor bleeding causes catastrophic complications. 1

Risk-Based Decision Algorithm

Continue Aspirin Throughout Surgery If:

• Patient has coronary stents (especially drug-eluting stents placed within 12 months or bare-metal stents within 30 days) 2
• Recent myocardial infarction or acute coronary syndrome 2
• High cardiovascular thrombotic risk that outweighs bleeding concerns 1
• Low bleeding risk procedures (dental work, most anterior segment eye surgery, peripheral vascular surgery) 2, 3

Stop Aspirin 5-7 Days Before Surgery If:

• Closed-space surgeries where minor bleeding causes severe complications:
  • Intracranial/neurosurgery 2, 1, 3
  • Spinal surgery in the medullary canal 3, 4
  • Posterior chamber eye surgery (vitreoretinal procedures) 3
• High bleeding risk procedures in patients WITHOUT high cardiovascular risk 1, 5
• Prostatectomy 2

Critical Timing Considerations:

• If aspirin must be stopped: Discontinue 5-7 days preoperatively (not the traditional 7-10 days) 2, 1, 5
• Restart aspirin: Within 12-24 hours postoperatively once adequate hemostasis is achieved 1, 5

Special Populations Requiring Continued Aspirin

Patients with Coronary Stents:

• Drug-eluting stents (DES): Ideally delay elective surgery until 12 months post-placement; if surgery cannot be delayed, continue aspirin throughout 2
• Bare-metal stents (BMS): Delay elective surgery until at least 30 days post-placement; continue aspirin if surgery is necessary 2, 1
• If dual antiplatelet therapy (aspirin + clopidogrel) is required: Stop clopidogrel 5 days before surgery but maintain aspirin, then restart clopidogrel within 5 days postoperatively 2

Cardiac Surgery Exception:

• For coronary artery bypass grafting (CABG): Aspirin should be continued or given within 48 hours of operation despite increased blood loss, as it improves graft patency and does not increase mortality 2, 1

Evidence on Bleeding Risk vs. Thrombotic Risk

The critical principle: Continuing aspirin increases the frequency of procedural bleeding (relative risk 1.5) but does NOT increase the severity of bleeding complications or perioperative mortality in most surgeries. 2, 1

• The thrombotic risk of stopping aspirin in high-risk patients overwhelms the bleeding risk in most procedures 4
• Exceptions where bleeding severity matters: intracranial surgery, closed-space procedures, and prostatectomy 2, 3

Common Pitfalls to Avoid

• Do not stop aspirin for 10 days: The traditional 7-10 day recommendation is excessive; 5-7 days is sufficient as only 20% of circulating platelets need normal function for hemostasis 1, 4
• Do not substitute heparin bridging for aspirin: This increases bleeding risk without providing adequate protection against coronary or stent thrombosis 4
• Do not assume all eye surgeries require stopping aspirin: Only posterior chamber procedures require discontinuation; anterior segment surgery can proceed on aspirin 3
• Obtain thorough medication history: Patients often fail to report over-the-counter NSAIDs with antiplatelet effects 1

Surgery-Specific Recommendations

High-Risk Bleeding Procedures (Stop Aspirin 5-7 Days Before):

• Neurosurgery 2, 1, 5
• Spinal surgery in medullary canal 3, 4
• Posterior chamber eye surgery 3
• Prostatectomy 2

Low-Risk Bleeding Procedures (Continue Aspirin):

• Dental procedures 2
• Anterior segment eye surgery 3
• Peripheral vascular surgery 2
• Carotid endarterectomy 2
• Most general surgical procedures in patients with cardiovascular risk 1