Should I stop aspirin before my elective surgery if I'm taking it for secondary cardiovascular prevention?

Should You Hold Aspirin Before Elective Surgery for Secondary Cardiovascular Prevention?

For most elective noncardiac surgeries, you should continue aspirin when taking it for secondary cardiovascular prevention, unless the procedure carries exceptionally high bleeding risk (intracranial neurosurgery or possibly transurethral prostatectomy). 1, 2

Risk-Benefit Framework

The decision hinges on balancing thrombotic versus bleeding risk, but the evidence strongly favors continuation in most scenarios:

Thrombotic Risks of Stopping Aspirin

• Discontinuing aspirin increases absolute risk of stroke recurrence or major cardiovascular events by approximately 2% within 30 days 1, 3, 4
• 70% of cardiovascular or cerebrovascular events occur within 7-10 days after aspirin discontinuation 3
• Aspirin withdrawal precedes up to 10.2% of acute cardiovascular syndromes, with events occurring at median 8.5 days for acute coronary syndromes and 14.3 days for cerebral events 5
• In high-risk patients undergoing intermediate- or high-risk noncardiac surgery, aspirin reduces major cardiac events by up to 80% 2, 4

Bleeding Risks of Continuing Aspirin

• Aspirin increases the frequency of procedural bleeding by relative risk 1.5, but does NOT increase the severity of bleeding complications or perioperative mortality 1, 2
• The STRATAGEM trial (291 patients) found no significant difference in major thrombotic or bleeding events between preoperative aspirin continuation versus interruption 6
• For cardiac surgery specifically, perioperative aspirin increases blood loss and transfusion requirements but does NOT increase mortality and improves saphenous vein graft patency 1

Surgery-Specific Recommendations

Continue Aspirin Throughout (Strong Recommendations)

• All patients with coronary stents - regardless of timing or stent type 1, 2
• Carotid endarterectomy 2
• Cardiac surgery (CABG) - continue aspirin and maintain postoperatively for improved graft patency 1
• Vascular surgery - routinely continued with improved peripheral bypass graft patency 1
• Orthopedic surgery including hip procedures - not classified as high bleeding risk 3
• Wound debridement and minor procedures 4

Consider Stopping Aspirin (Limited Exceptions)

• Intracranial neurosurgery - stop 5-7 days preoperatively due to catastrophic consequences of even minor bleeding 1, 2, 3
• Possibly transurethral prostatectomy - conflicting evidence but may warrant discontinuation 1, 5

The 2014 ACC/AHA 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" only when risk of ischemic events does NOT outweigh bleeding risk 1

Practical Management Algorithm

Step 1: Identify Indication for Aspirin

• Secondary prevention (prior MI, stroke, peripheral arterial disease, coronary stents) → Continue aspirin 1, 2
• Primary prevention only → Discontinue aspirin 1

Step 2: Assess Surgery Type

• Closed-space surgery (intracranial) → Stop aspirin 5 days before surgery 1, 3
• All other surgeries → Continue aspirin 1, 2

Step 3: Special Considerations for Coronary Stents

• Bare-metal stent <30 days or drug-eluting stent <12 months → Delay elective surgery if possible 1
• If surgery cannot be delayed → Continue aspirin AND dual antiplatelet therapy during first 4-6 weeks after stent placement 1
• If P2Y12 inhibitor must be stopped → Continue aspirin and restart P2Y12 inhibitor as soon as possible postoperatively 1

Step 4: Postoperative Management

• Resume aspirin within 24 hours after surgery when adequate hemostasis achieved 2, 3, 4
• Do NOT use heparin bridging - this increases bleeding without preventing thrombotic events 3, 4

Timing Details When Discontinuation Is Necessary

If you must stop aspirin (rare exceptions only):

• Aspirin's hemostatic effects normalize within 5-6 days - all bleeding times normalized within 96 hours and platelet function within 144 hours 7
• Stop aspirin 5 days before surgery (not the traditional 7-10 days) 1, 2, 7
• No difference in duration of effect between 75 mg and 300 mg doses 7

Critical Pitfalls to Avoid

• Do NOT routinely discontinue aspirin for all surgeries - this outdated practice increases mortality and morbidity 4
• Do NOT confuse secondary prevention with primary prevention - only primary prevention aspirin should be stopped 1, 3
• Do NOT bridge with heparin or LMWH when discontinuing aspirin 3, 4
• Do NOT delay resumption postoperatively - restart within 12-24 hours unless active bleeding 4
• Do NOT stop aspirin in patients with coronary stents - this markedly increases risk of catastrophic stent thrombosis, death, and MI 2, 3

Strength of Evidence

The 2014 ACC/AHA perioperative guidelines (Class IIa, Level B) state it is "reasonable to continue aspirin when the risk of increased cardiac events outweighs the risk of increased bleeding" 1. The 2018 French Working Group on Perioperative Haemostasis achieved "strong agreement" that aspirin should not be discontinued preoperatively when prescribed for secondary prevention, except for high bleeding risk procedures 1. These recommendations are supported by the 2007 ACC/AHA guidelines emphasizing continuation benefits 1 and the 2023 ACC/AHA CABG performance measures reinforcing perioperative aspirin continuation 1.