Aspirin Management for Hip Replacement Surgery

Primary Recommendation: Continue Aspirin

The American College of Chest Physicians recommends continuing aspirin perioperatively for patients undergoing hip replacement, particularly those taking it for cardiovascular indications 1, 2, 3
The landmark PEP trial demonstrated that aspirin reduced VTE risk (RR 0.71; 95% CI: 0.54-0.94) with only a modest increase in major bleeding (2.9% vs 2.4%; P = 0.04) in 17,444 patients undergoing hip fracture repair or hip/knee replacement 1, 2, 3, 4

The American College of Chest Physicians specifically recommend stopping aspirin ≤7 days (meaning 7 days or less) rather than the outdated 7-10 day window 1, 2
Since aspirin irreversibly inhibits platelet function, 7 days allows for adequate platelet turnover to restore hemostasis 3, 4
For hip replacement specifically, 5-7 days of interruption is sufficient if holding is deemed necessary, according to the American College of Chest Physicians guidelines 1

The American College of Chest Physicians recommend resuming aspirin within 24 hours after surgery once adequate hemostasis is achieved 5, 6
Maximal antiplatelet effect occurs within minutes of taking aspirin, providing immediate cardiovascular and VTE protection 2, 3, 4
For patients with coronary stents or high cardiovascular risk, the American College of Chest Physicians recommend restarting aspirin as soon as possible postoperatively, ideally within the first 24 hours 5, 6

The POISE-2 trial showed that aspirin continuation did not increase major bleeding significantly (4.6% vs 4.1%; HR 1.11; 95% CI: 0.84-1.48) 1, 2, 4
Continuing aspirin increases the frequency but not the severity of bleeding complications, according to the American College of Chest Physicians guidelines 1, 2

The American College of Chest Physicians recommend not holding aspirin for 10 days, as this is outdated practice that unnecessarily increases thrombotic risk without additional bleeding benefit 5, 6
The American College of Chest Physicians recommend not assuming all patients need aspirin held, as hip replacement is not a closed-space surgery where minor bleeding causes catastrophic complications 5
Ensure thorough medication reconciliation, as patients may not report over-the-counter NSAIDs that compound antiplatelet effects, according to the American College of Chest Physicians guidelines 5, 6
For patients on dual antiplatelet therapy, the American College of Chest Physicians recommend continuing aspirin but holding the P2Y12 inhibitor (clopidogrel 5 days, ticagrelor 3-5 days, prasugrel 7 days before surgery) 6

The American College of Chest Physicians recommends continuing aspirin for 35 days after hip replacement surgery when initiated specifically for thromboprophylaxis, based on the Pulmonary Embolism Prevention trial of 19,000 patients undergoing hip fracture repair or joint replacement, which demonstrated that 35 days of aspirin reduced VTE risk (RR 0.71, 95% CI 0.54-0.94) with only a modest increase in major bleeding (2.9% vs 2.4%, P=0.04) 7, 8
The American College of Chest Physicians recommends continuing aspirin indefinitely throughout the perioperative period for patients taking it for secondary prevention of cardiovascular disease, including patients with prior myocardial infarction, prior stroke, coronary stents, ischemic heart disease, compensated or prior congestive heart failure, diabetes mellitus, renal insufficiency, or cerebrovascular disease 7, 8, 9, 10

The benefit of extended-duration anticoagulants must be weighed against increased risk of minor bleeding (OR 2.01, 95% CI 1.43-2.81), according to a study cited by the American College of Chest Physicians 7

For patients on aspirin plus clopidogrel, the American College of Chest Physicians recommends continuing aspirin but stopping clopidogrel 5 days before surgery 9