Can a patient with a history of cardiovascular disease stop taking aspirin (acetylsalicylic acid) before undergoing surgery?

Perioperative Aspirin Management in Cardiovascular Disease Patients

For patients with established cardiovascular disease taking aspirin, continuation through the perioperative period is generally recommended for most surgeries, with discontinuation reserved only for closed-space procedures (neurosurgery, intracranial surgery, intramedullary spine surgery) where even minor bleeding causes catastrophic complications. 1, 2

Decision Framework Based on Surgery Type and Patient Risk

Continue Aspirin Throughout Perioperative Period

For CABG (Coronary Artery Bypass Grafting):

• Patients already taking aspirin preoperatively should continue it through the perioperative period and be discharged on aspirin 3
• Continuation is associated with reduced risk of myocardial infarction, improved vein graft patency, and reduced ischemic complications, despite increased perioperative bleeding that does not increase surgical reoperation rates 3
• Aspirin should be started within 6 hours postoperatively if not already taking it preoperatively 3

For Patients with Coronary Stents:

• Aspirin must be continued perioperatively regardless of stent type 3, 1
• For bare-metal stents: elective surgery should be delayed 4-6 weeks after placement, but aspirin continues throughout 3
• For drug-eluting stents: elective surgery should be delayed 12 months after placement, with aspirin continued throughout the perioperative period 3, 1
• Premature discontinuation markedly increases risk of catastrophic stent thrombosis, death, and myocardial infarction 3

For Carotid Endarterectomy:

• Aspirin continuation is specifically recommended 3

For Most Non-Cardiac Surgery in High CV Risk Patients:

• Patients with established coronary artery disease, prior ischemic stroke, or peripheral arterial disease should continue aspirin 1, 2
• The ASINC trial showed aspirin reduced major cardiac events by 80% in patients with cardiac risk factors undergoing intermediate- or high-risk non-cardiac surgery 3

Discontinue Aspirin Before Surgery

For Closed-Space Procedures:

• Neurosurgery and intracranial surgery: stop aspirin 5-7 days preoperatively 3, 1, 4
• Intramedullary spine surgery: discontinuation warranted 5
• These procedures carry risk of severe complications from even minor bleeding 1, 4

For Intracranial Neurosurgery Specifically:

• Last aspirin intake should be on D-5 (5 days before surgery) 3

For Primary Prevention Only (No Established CV Disease):

• Aspirin should be discontinued before surgery, especially when bleeding risk is high 1, 2
• The POISE-2 trial showed no benefit in reducing myocardial infarction or mortality but increased major bleeding in patients without significant cardiovascular history 3, 5

Timing of Discontinuation When Required

Standard Timing:

• For most elective surgeries requiring discontinuation: stop aspirin 3 days before surgery (D-3) 3, 1
• Traditional 7-10 day discontinuation is longer than necessary; ≤7 days is typically sufficient 1, 4

For High-Risk Bleeding Procedures:

• Intracranial neurosurgery: 5 days preoperatively 3
• Patients with coagulation disorders: 5-10 days preoperatively 4

Resumption of Aspirin Therapy

• Restart aspirin within 24 hours after surgery when adequate hemostasis is achieved 1
• For high thrombotic risk patients, resume as soon as possible postoperatively 1
• If thienopyridines (clopidogrel, ticagrelor, prasugrel) were discontinued, restart them as soon as possible while continuing aspirin 3, 1

Risk-Benefit Analysis

Bleeding Risk with Continuation:

• Aspirin increases frequency of procedural bleeding by relative risk of 1.5 1, 6
• However, it typically does not increase severity of bleeding complications or perioperative mortality 1, 6
• Baseline bleeding frequency varies by procedure: 0% for cataract surgery to 75% for transrectal prostate biopsy 6

Thrombotic Risk with Discontinuation:

• Aspirin withdrawal precedes up to 10.2% of acute cardiovascular syndromes 6
• Time interval between discontinuation and acute events: 8.5 ± 3.6 days for acute coronary syndromes, 14.3 ± 11.3 days for cerebral events 6
• Discontinuation of antiplatelet therapy increases absolute risk of stroke recurrence or cardiovascular event by approximately 2% within 30 days 3

Critical Caveats

Avoid These Common Errors:

• Do not discontinue aspirin for 10 days when 7 days or less is sufficient 1
• Do not stop aspirin in patients with coronary stents within 30 days of bare-metal stent or 12 months of drug-eluting stent placement 3, 1
• Ensure thorough medication reconciliation as patients may not report over-the-counter NSAID use with antiplatelet effects 1
• Do not reduce aspirin dosage before surgery in patients on long-term aspirin up to 300 mg/day 3

Special Considerations:

• Aspirin can be continued on a case-by-case basis, with the decision based on weighing thrombotic risk against surgical bleeding risk 3, 1
• For cardiovascular and vascular surgery, orthopedic surgery, and epidural anesthesia, no clinically relevant bleeding complications have been reported with aspirin continuation 4
• The ASA guidelines note that aspirin may be continued on a case-by-case basis, but caution that clopidogrel and aspirin should not be stopped in patients with coronary stents placed within specific timeframes 3