How long should aspirin be held after surgery?

Aspirin Resumption After Surgery

Aspirin should be restarted within 24 hours after surgery in patients with established cardiovascular disease, once adequate hemostasis is achieved. 1

Immediate Postoperative Management (First 24 Hours)

For patients with coronary artery disease, prior stroke, or peripheral arterial disease, restart aspirin as soon as possible postoperatively, ideally within the first 24 hours, as discontinuation increases the absolute risk of stroke recurrence or cardiovascular events by approximately 2% within 30 days. 1 The American College of Chest Physicians emphasizes that aspirin should be continued or restarted as soon as possible after surgery, typically within 24 hours once adequate hemostasis is achieved. 1

In patients with coronary stents who required aspirin interruption, restart aspirin immediately postoperatively and resume the P2Y12 inhibitor as soon as possible, due to the high thrombotic risk in this population. 2, 1 The American College of Cardiology specifically recommends that aspirin be continued throughout the perioperative period in patients with prior PCI, and if interrupted, should be restarted immediately postoperatively. 1

Surgery-Specific Timing Considerations

For most non-cardiac surgeries, aspirin can be safely restarted within 24 hours. 1 However, specific procedures require modified timing:

• High bleeding risk procedures (neurosurgery, intracranial surgery): Delay aspirin resumption until the surgeon confirms adequate hemostasis and acceptable bleeding risk. 1
• Closed-space posterior chamber eye procedures (vitreoretinal surgery): Aspirin should have been discontinued 5 days before surgery and timing of resumption should be determined by the ophthalmologist based on hemostasis. 2, 3
• Coronary artery bypass grafting: Aspirin should be started within 48 hours after surgery to reduce saphenous vein graft closure, with dosing regimens ranging from 100 to 325 mg/d appearing efficacious. 2

Critical High-Risk Populations

For patients with drug-eluting stents (DES) or bare-metal stents (BMS), aspirin continuation is paramount. 2 If dual antiplatelet therapy (DAPT) was continued during surgery, maintain both agents postoperatively. 2 If the P2Y12 inhibitor was held, restart it as soon as possible after surgery while maintaining aspirin throughout. 2, 1

The European Society of Cardiology guidelines emphasize that DAPT should be administered for at least 1 month after BMS implantation in stable CAD, for 6 months after new-generation DES implantation, and for up to 1 year in patients after acute coronary syndrome. 2 A minimum of 1 (BMS) to 3 (new-generation DES) months of DAPT might be acceptable when surgery cannot be delayed for a longer period. 2

Dosing Recommendations

The maintenance dose should be 75-162 mg daily for long-term secondary prevention. 2, 1 The American College of Cardiology recommends 75-100 mg daily for long-term secondary prevention. 1

Important Caveats and Pitfalls

Do not withhold aspirin indefinitely postoperatively in cardiovascular disease patients, as thrombotic events cluster early after discontinuation, with the highest risk in the first 30 days. 1 The European Society of Cardiology and other guideline societies emphasize this critical timing. 1

Avoid combination therapy with multiple antiplatelet or anticoagulant medications immediately postoperatively without careful risk assessment, as bleeding risk increases significantly with combination therapy. 1 The American Heart Association specifically warns against this practice. 1

Ensure medication reconciliation to verify patients are not taking over-the-counter NSAIDs with antiplatelet effects, which can impair aspirin's cardioprotective effects and increase bleeding risk. 1

For patients on dual antiplatelet therapy, understand the timing of P2Y12 inhibitor resumption: clopidogrel takes 4-5 days with maintenance dosing, prasugrel takes 3 days, and ticagrelor takes 2 hours to achieve maximal effect. 1 This knowledge is essential for planning adequate thrombotic protection.

Primary Prevention Patients

For patients taking aspirin for primary prevention (no established cardiovascular disease) who underwent noncardiac surgery, aspirin can be discontinued perioperatively and does not need to be restarted, as shown by the POISE-2 trial. 1 The American College of Cardiology guidelines state that initiation or continuation of aspirin is not beneficial in patients undergoing elective noncardiac noncarotid surgery who have not had previous coronary stenting. 2