When should Acetylsalicylic acid (Aspirin) be discontinued prior to surgery?

From the Guidelines

Aspirin should be stopped 5 days before surgery for patients undergoing high-risk procedures, such as neurosurgery, to minimize the risk of bleeding complications, as recommended by the most recent and highest quality study 1. When considering the management of antiplatelet therapy in patients undergoing elective invasive procedures, it is essential to weigh the risks of bleeding against the benefits of cardiovascular protection.

• The decision to stop aspirin before surgery depends on various factors, including the type of surgery, individual patient risk factors, and the specific antiplatelet regimen.
• For patients with coronary stents or high cardiovascular risk, aspirin might be continued through surgery or stopped only 3 days before, depending on the bleeding risk of the procedure, as suggested by previous studies 1.
• Low-dose aspirin (81 mg) may sometimes be continued for cardiac patients even during surgery, while higher doses (325 mg) generally require discontinuation, as noted in earlier guidelines 1.
• However, the most recent study 1 provides the strongest evidence for stopping aspirin 5 days before high-risk procedures, and this recommendation should be prioritized to minimize bleeding complications.
• It is crucial to consult with the surgeon and cardiologist before stopping aspirin, as the decision requires a careful balance between bleeding risk and cardiovascular protection.
• In emergency surgeries, the medical team may use platelet transfusions or other medications to counteract aspirin's effects if necessary, as mentioned in previous studies 1.

From the Research

Aspirin Management Before Surgery

• The decision to stop aspirin before surgery depends on various factors, including the type of surgery, patient's medical history, and risk of bleeding or thrombosis 2.
• Patients taking aspirin for primary prevention of cardiovascular disease may need to discontinue it before surgery, especially if there is a high risk of bleeding 2.
• However, patients with established cardiovascular disease, such as those with coronary artery disease or cerebrovascular disease, may need to continue aspirin during the perioperative period unless they are undergoing closed-space surgery 2.
• The traditional recommendation to stop aspirin 7-10 days before coronary artery bypass surgery may not be necessary, as some studies suggest that continuing aspirin until the time of surgery may not increase the risk of bleeding 3.

Risks and Benefits of Aspirin Continuation

• Continuing aspirin during the perioperative period may increase the risk of bleeding, but it may also reduce the risk of thrombotic events 4, 5.
• The risk of bleeding associated with aspirin continuation may be outweighed by the benefits of reducing thrombotic events in patients with high cardiovascular risk 2.
• However, the decision to continue or discontinue aspirin should be made on a patient-specific basis, taking into account the individual's medical history, surgical procedure, and risk factors 2.

Timing of Aspirin Withdrawal

• Aspirin withdrawal 5 days before high-bleeding-risk procedures may be associated with functional platelet recovery, and its reintroduction 2 days after surgery may restore antiplatelet efficacy 5 days later 6.
• However, the optimal timing of aspirin withdrawal and reintroduction may vary depending on the individual patient and surgical procedure, and further studies are needed to define the best approach 6.