Perioperative Aspirin Cessation Before Surgery
Perioperative management of aspirin is guided by individualized bleeding-risk versus thrombotic-risk assessment for the planned procedure and the patient’s cardiovascular history. [1],[2] When aspirin interruption is required for elective surgery, the CHEST guideline suggests stopping aspirin no later than 7 days before surgery. [1] For noncardiac surgery when aspirin must be interrupted, the 2024 AHA/ACC perioperative cardiovascular guideline indicates a 4- to 5-day preoperative discontinuation window. [2]
Medication Selection Algorithm
Aspirin continuation is favored when surgical bleeding risk is low and thrombotic risk from interruption is high. [1],[2] Aspirin interruption is reserved for procedures with higher bleeding risk where discontinuation is required by the surgical field. [1],[2]
Timing of Aspirin Cessation When Interruption Is Required
Aspirin interruption for elective surgery should be limited to a cessation window of ≤ 7 days before surgery. [1] For noncardiac surgery when interruption is needed, aspirin should be stopped 4 to 5 days before surgery. [2]
Monotherapy Versus Combination Antiplatelet Considerations
For patients receiving single-agent aspirin, perioperative decisions focus on continuation versus interruption based on procedure bleeding risk versus patient thrombotic risk. [1],[2] For patients receiving dual antiplatelet therapy, perioperative management should follow dual-therapy guidance because stopping decisions for P2Y12 inhibitors differ from aspirin timing. [1]
Important Clarifications and Nuances
Continuation of aspirin is considered reasonable in selected patients when the risk of cardiac events outweighs the risk of bleeding for elective noncardiac surgery. [2] In selected circumstances with higher thrombotic risk, perioperative planning should incorporate cardiology input because interruption may increase thrombotic risk. [2]
Targets and Goals of Therapy
The goal of perioperative aspirin management is minimization of major thromboembolic events from interruption while also minimizing major surgical bleeding from continued antiplatelet effect. [1],[2]
Common Pitfalls to Avoid
Stopping aspirin for elective surgery without a clear bleeding-risk indication increases risk of thrombotic events relative to strategies that continue aspirin in appropriate patients. [1],[2] Using cessation intervals longer than necessary for elective surgery increases the duration of time without antiplatelet effect when aspirin interruption is still required. [1]
Postoperative Resumption of Aspirin
CHEST guidance supports resumption of antiplatelet therapy after surgery based on postoperative bleeding status, using the same perioperative antithrombotic management framework applied to the decision for preoperative interruption versus continuation. [1]