How Long to Hold Baby Aspirin Before Foot Surgery
For patients with cardiovascular disease undergoing elective foot surgery, aspirin should be discontinued 3 days before surgery (last dose on day -3), unless the patient has a coronary stent, in which case aspirin should be continued throughout the perioperative period. 1
Decision Algorithm Based on Cardiovascular Status
Patients WITHOUT Coronary Stents
For secondary cardiovascular prevention (prior MI, stroke, or peripheral arterial disease):
- Stop aspirin 3 days before foot surgery (last intake on day -3, where day 0 is the surgery date) 1
- This shorter discontinuation window (≤7 days) is now preferred over the outdated 7-10 day recommendation 1, 2
- Resume aspirin within 24 hours after surgery once adequate hemostasis is achieved 1, 2, 3
The French Working Group on Perioperative Haemostasis specifically recommends a 3-day discontinuation for aspirin before most surgical procedures, which represents the most current evidence-based timing 1. The American College of Chest Physicians supports stopping aspirin ≤7 days before surgery, with the understanding that shorter durations are acceptable 1.
Patients WITH Coronary Stents
Continue aspirin throughout the perioperative period 2, 4
- This applies to both bare-metal stents and drug-eluting stents 2, 4
- Discontinuing aspirin in stent patients increases risk of catastrophic stent thrombosis, death, and myocardial infarction 2
- If dual antiplatelet therapy is being used, continue aspirin but stop the P2Y12 inhibitor (clopidogrel 5 days before, ticagrelor 3-5 days before, prasugrel 7 days before) 1, 4
Bleeding Risk Considerations for Foot Surgery
Foot surgery is generally classified as intermediate bleeding risk, not high-risk like intracranial or spinal procedures 3. This classification supports the ability to safely continue aspirin in high-risk cardiovascular patients, particularly those with stents 2, 3.
For patients with established cardiovascular disease but without stents, the thrombotic risk of aspirin discontinuation must be weighed against bleeding risk 1. Studies show that discontinuing antiplatelet therapy increases the absolute risk of stroke recurrence or cardiovascular events by approximately 2% within 30 days 1, 2.
Physiologic Rationale
Aspirin's antiplatelet effects persist for the lifespan of affected platelets 5. Research demonstrates that:
- All bleeding times normalize within 96 hours (4 days) after stopping aspirin 5
- All platelet function tests normalize within 144 hours (6 days) 5
- No demonstrable hemostatic defect persists by the sixth day after cessation 5
This supports the 3-day discontinuation recommendation, as surgery performed on day 0 (with last aspirin dose on day -3) allows sufficient time for platelet recovery 1, 5.
Critical Caveats and Common Pitfalls
Avoid these errors:
- Do not discontinue aspirin for 7-10 days - this outdated practice unnecessarily prolongs thrombotic risk 1, 2, 4
- Do not stop aspirin in patients with coronary stents - this can be catastrophic 2, 4
- Do not reduce aspirin dosage before surgery - patients on long-term aspirin up to 300 mg/day should maintain their usual dose until discontinuation 1
- Perform thorough medication reconciliation - patients may not report over-the-counter NSAIDs with antiplatelet effects 2, 3
Postoperative Management
Resume aspirin within 24 hours after surgery when adequate hemostasis is achieved 1, 2, 4, 3. For patients with drug-eluting stents, some experts recommend a 300 mg loading dose of clopidogrel when resuming dual antiplatelet therapy 4, 3.
The risk-benefit analysis clearly favors aspirin continuation in high-risk cardiovascular patients (especially those with stents) and brief discontinuation (3 days) in others, as aspirin increases bleeding frequency by only 1.5-fold without increasing severity of bleeding complications in most surgical contexts 2, 6.