Should a patient with a history of cardiovascular disease stop taking aspirin before undergoing surgery?

Should Aspirin Be Stopped Before Surgery in Patients with Cardiovascular Disease?

For patients with cardiovascular disease, aspirin should generally be CONTINUED throughout the perioperative period, with specific exceptions based on bleeding risk and coronary stent status. The decision hinges on whether the patient has coronary stents and the type of surgery planned.

Patients WITH Coronary Stents: Continue Aspirin

Aspirin must be continued perioperatively in all patients with coronary stents, regardless of stent type. 1, 2, 3, 4

• Premature discontinuation of aspirin markedly increases the risk of catastrophic stent thrombosis, death, and myocardial infarction 2, 4
• For bare-metal stents (BMS): Elective surgery should ideally be delayed at least 30 days after placement, but if surgery cannot be delayed, continue aspirin throughout 1, 3
• For drug-eluting stents (DES): Elective surgery should optimally be delayed 12 months after placement (minimum 6 months if risk is acceptable), but aspirin must be continued if surgery proceeds 1, 2, 3, 4

Dual Antiplatelet Therapy Management

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

• Continue aspirin throughout the perioperative period 1, 2
• Stop the P2Y12 inhibitor 5 days before surgery 1, 2, 3
• Restart the P2Y12 inhibitor as soon as possible postoperatively, ideally within 5 days 1
• Median time to stent thrombosis is 7 days when both agents are stopped, but 122 days when aspirin is maintained 1

Patients WITHOUT Stents: Risk-Stratified Approach

High Cardiovascular Risk (Continue Aspirin)

Continue aspirin perioperatively for patients with: 1, 2, 3

• Established coronary artery disease
• Prior myocardial infarction or acute coronary syndrome
• History of ischemic stroke
• Peripheral arterial disease
• Patients undergoing carotid endarterectomy 2, 3
• Patients undergoing cardiac surgery (CABG), where continuation reduces MI risk and improves graft patency 2, 4

The evidence shows aspirin reduces major cardiac events by 80% in high-risk patients undergoing intermediate- or high-risk noncardiac surgery 2. Discontinuing antiplatelet therapy increases the absolute risk of stroke recurrence or cardiovascular events by approximately 2% within 30 days 2.

Lower Cardiovascular Risk: Consider Stopping

For patients with cardiovascular disease but lower acute thrombotic risk and undergoing high bleeding-risk procedures:

• Stop aspirin 5-7 days before surgery (NOT the traditional 7-10 days) 2, 3, 4, 5
• Platelet function normalizes within 96 hours, and all hemostatic defects resolve by day 6 after cessation 5
• Resume aspirin within 24 hours postoperatively once adequate hemostasis is achieved 2, 3, 4

Surgery-Specific Bleeding Risk Considerations

HIGH Bleeding Risk (Consider Stopping Aspirin 5-7 Days Prior)

Stop aspirin 5-7 days preoperatively for: 2, 3, 6, 7

• Neurosurgery and spinal surgery (where even minor bleeding causes severe complications)
• Intracranial procedures
• Posterior chamber eye surgery
• Prostatectomy
• Closed-space surgeries

For spine surgery specifically, stopping aspirin 7-10 days preoperatively eliminates increased bleeding risk, while stopping for only 3-7 days still carries elevated risk 7.

LOW Bleeding Risk (Continue Aspirin)

Continue aspirin throughout surgery for: 2, 3

• Dental procedures
• Anterior segment eye surgery (e.g., cataract surgery)
• Peripheral vascular surgery
• Most dermatological procedures

Evidence on Bleeding vs. Thrombotic Risk

The POISE-2 trial (10,010 patients) showed that aspirin did not reduce major adverse cardiac events or death in unselected patients undergoing noncardiac surgery, but did increase major bleeding 1. However, this trial excluded patients within 6 weeks of BMS or 1 year of DES placement, and only 23% had known coronary artery disease 1.

Key evidence points:

• Continuing aspirin increases the frequency of procedural bleeding (relative risk 1.5) but does NOT increase the severity of bleeding complications or perioperative mortality in most surgeries 1, 2, 4, 6
• In cardiac surgery, perioperative aspirin increases blood loss but does NOT increase mortality and improves saphenous vein graft patency 1, 4

Critical Pitfalls to Avoid

• Never stop aspirin in patients with coronary stents without cardiology consultation 1, 2
• Do not discontinue aspirin for longer than necessary—5-7 days is sufficient, not 7-10 days 2, 4, 5
• Do not reduce aspirin dosage before surgery in patients on long-term therapy up to 300 mg/day 2
• Ensure thorough medication reconciliation, as patients may not report over-the-counter NSAID use 2
• The risk of stopping antiplatelet therapy should be weighed against bleeding risk on a case-by-case basis, but when in doubt in stented patients, continue aspirin 1