Should Ecosprin (aspirin) be continued or stopped before an operative procedure?

Perioperative Management of Ecosprin (Aspirin)

Direct Recommendation

For most patients undergoing elective surgery, aspirin should be continued perioperatively unless the procedure involves closed-space surgery (intracranial, spinal canal, posterior chamber eye surgery, or prostatectomy), in which case it should be stopped 5-7 days before the procedure. 1, 2

Risk-Stratification Algorithm

Continue Aspirin Throughout Surgery For:

• Patients with coronary stents:

  • Drug-eluting stents placed within 12 months 1, 3
  • Bare-metal stents placed within 30 days to 6 weeks 1, 3
  • Any patient with history of stent thrombosis, left main stenting, or multivessel stenting 3

• High cardiovascular thrombotic risk patients:

  • Recent myocardial infarction or acute coronary syndrome 1
  • History of stroke or TIA on aspirin for secondary prevention 3, 1
  • Established coronary artery disease, cerebrovascular disease, or peripheral arterial disease 4, 5

• Low bleeding risk procedures:

  • Dental procedures 1, 6
  • Anterior segment eye surgery 1
  • Peripheral vascular surgery and carotid endarterectomy 1
  • Inguinal hernia repair 7
  • Endoscopic procedures without high-risk interventions 3

Stop Aspirin 5-7 Days Before Surgery For:

• High bleeding risk closed-space procedures:

  • Intracranial/neurosurgery 1, 2
  • Spinal surgery within the medullary canal 1
  • Posterior chamber eye surgery 1
  • Transurethral prostatectomy 1, 5

• Patients on aspirin for primary prevention only (no established cardiovascular disease):

  • Especially when bleeding risk is significant 4, 3

Special Considerations for Dual Antiplatelet Therapy

If patient is on both aspirin and clopidogrel (P2Y12 inhibitor):

• Stop clopidogrel 5 days before surgery 1, 2
• Continue aspirin throughout the perioperative period 3, 1
• Restart clopidogrel within 5 days postoperatively, ideally within 12-24 hours once hemostasis is achieved 1, 3

For patients requiring dual antiplatelet therapy who cannot delay surgery:

• Continue both agents if stent was placed <30 days (bare-metal) or <12 months (drug-eluting), as stent thrombosis carries catastrophic mortality risk 3, 8
• Consult with interventional cardiologist for high-risk cases 3

Timing of Aspirin Resumption

Restart aspirin within 12-24 hours postoperatively once adequate hemostasis is achieved 1, 2, 8

• For patients with acute GI hemorrhage on aspirin for secondary prevention, recommence as soon as hemostasis is achieved or bleeding stops 3
• Earlier resumption (within 6 hours) is recommended for CABG patients 3

Evidence on Bleeding vs. Thrombotic Risk

Continuing aspirin increases the frequency of procedural bleeding by a relative risk of 1.5, but does not increase the severity of bleeding complications or perioperative mortality in most surgeries 5, 1, 2

• Exceptions where bleeding severity matters: intracranial surgery, closed-space procedures, and prostatectomy 5, 1
• In inguinal hernia repair, no significant difference in bleeding complications between aspirin continuation vs. cessation 7
• In dental surgery, bleeding time increases but remains within normal range, and local hemostatic measures are sufficient 6

Cardiovascular risks of aspirin withdrawal:

• Aspirin withdrawal precedes up to 10.2% of acute cardiovascular syndromes 5
• Time to acute event after withdrawal: 8.5 days for acute coronary syndromes, 14.3 days for cerebral events 5
• Rebound hypercoagulability occurs when aspirin is stopped, compounded by surgery-induced prothrombotic state 9

Critical Pitfalls to Avoid

• Do not stop aspirin for longer than necessary - if it must be stopped, 5-7 days is sufficient, not the traditional 7-10 days 1, 2
• Do not stop aspirin in patients with recent coronary stents - stent thrombosis risk far outweighs bleeding risk 3, 1
• Do not permanently discontinue aspirin after GI bleeding if used for secondary prevention - restart once hemostasis achieved 3
• Do not delay elective surgery indefinitely - if surgery cannot wait, continue aspirin and manage bleeding risk intraoperatively 3, 1
• Do not forget to obtain thorough medication history - patients may not report over-the-counter aspirin or NSAIDs 2

Endoscopic Procedures Specific Guidance

Continue aspirin for:

• Low-risk procedures: diagnostic endoscopy with biopsy, biliary/pancreatic stenting, EUS without sampling 3

Consider stopping aspirin for:

• High-risk procedures: polypectomy, EMR/ESD, ERCP with sphincterotomy, variceal therapy 3
• Resume 2-3 days after procedure depending on hemorrhagic and thrombotic risks 3