Latest Guidelines on Stopping Aspirin Before Surgery
For most elective non-cardiac surgeries, stop aspirin ≤7 days (not the traditional 7-10 days) before the procedure when interruption is necessary, and resume within 24 hours postoperatively once hemostasis is achieved. 1
Decision Framework: Continue vs. Stop Aspirin
The decision hinges on balancing thrombotic risk against surgical bleeding risk. Here's how to approach this systematically:
When to CONTINUE Aspirin (Do Not Stop)
Patients with coronary stents (any type): Continue aspirin throughout the perioperative period regardless of stent type, as premature discontinuation markedly increases risk of catastrophic stent thrombosis, death, and myocardial infarction 1, 2
CABG surgery: Continue aspirin perioperatively, as it reduces myocardial infarction risk and improves vein graft patency 1, 2
Carotid endarterectomy: Aspirin continuation is specifically recommended 2
High cardiovascular risk patients (established coronary artery disease, prior ischemic stroke, peripheral arterial disease) undergoing non-cardiac surgery: Continue aspirin, as trials show 80% reduction in major cardiac events 2, 3
Low-to-moderate bleeding risk procedures: Continue aspirin when thrombotic risk outweighs bleeding concerns 1, 2
When to STOP Aspirin
Closed-space surgeries (neurosurgery, spinal surgery, intracranial procedures): Stop aspirin 5-7 days preoperatively, as even minor bleeding can cause severe complications 1, 2, 4
Neuraxial procedures (epidurals, spinals): Stop aspirin 5 days before the procedure to allow complete correction of platelet function 5
Primary prevention patients (no established cardiovascular disease): Stop aspirin during the perioperative period, especially with high bleeding risk 3
High bleeding-risk surgeries in patients without coronary stents or recent acute coronary syndrome: Stop aspirin ≤7 days preoperatively 1
Specific Timing Recommendations
Preoperative Discontinuation
- Standard recommendation: Stop ≤7 days before surgery (not 7-10 days) 1
- Neuraxial/closed-space procedures: Stop 5-7 days before surgery 2, 5, 4
- Foot surgery with cardiovascular disease: Stop 3 days before surgery (unless patient has coronary stent) 2
Postoperative Resumption
- Resume within 24 hours after surgery when adequate hemostasis is achieved 1, 2
- For high thrombotic risk patients (recent stents, stroke), restart as soon as possible, ideally within the first 24 hours 2, 6
- For CABG patients, resume within 24 hours postoperatively 1
Special Populations Requiring Extra Caution
Patients with Coronary Stents
Bare-metal stents (BMS): Delay elective surgery for at least 30 days after placement; continue dual antiplatelet therapy (DAPT) if surgery occurs within first 4-6 weeks 1
Drug-eluting stents (DES): Delay elective surgery optimally for 365 days (12 months), but may consider after 180 days if further complication risk is low 1
Critical timing: Elective surgery should NOT be performed if DAPT must be discontinued within 30 days of BMS or within 12 months of DES placement 1
If surgery cannot be delayed: Continue both antiplatelet agents or stop only the P2Y12 inhibitor while maintaining aspirin 1
Patients on Dual Antiplatelet Therapy (DAPT)
- Continue DAPT during urgent surgery in first 4-6 weeks after stent placement unless bleeding risk outweighs stent thrombosis prevention 1
- If P2Y12 inhibitor must be stopped, continue aspirin and restart P2Y12 inhibitor as soon as possible postoperatively 1
- Management should be determined by consensus of treating clinicians and the patient 1
Common Pitfalls to Avoid
Stopping aspirin too long: Many clinicians unnecessarily discontinue aspirin for 10 days when ≤7 days is sufficient 1, 2
Underestimating thrombotic risk: Discontinuing antiplatelet therapy increases absolute risk of stroke recurrence or cardiovascular event by approximately 2% within 30 days 2
Missing over-the-counter NSAIDs: Patients may not report OTC NSAID use with antiplatelet effects; thorough medication reconciliation is essential 2
Premature stent surgery: Operating on patients with recent stents before appropriate waiting periods dramatically increases mortality risk 1
Epidural catheter manipulation: Catheter removal carries the same bleeding risk as insertion; apply the same aspirin discontinuation criteria 5
Combining antiplatelet agents: Bleeding risk significantly increases when multiple antiplatelet or anticoagulant medications are combined 2
Risk-Benefit Analysis
Bleeding risks: Continuing aspirin may increase procedural bleeding frequency (relative risk 1.5) but typically does not increase severity of bleeding complications or perioperative mortality 2
Thrombotic risks: For cardiac surgery, perioperative aspirin may increase blood loss but does not increase mortality and is associated with improved bypass graft patency 2
Primary prevention: Recent trials question aspirin's efficacy for primary prevention, making perioperative discontinuation more reasonable in this population 3