Postoperative Aspirin Therapy

Introduction to Aspirin Therapy

The American College of Cardiology and European Heart Society recommend that aspirin should be started within 6-48 hours after surgery and continued indefinitely for patients undergoing coronary artery bypass grafting (CABG), while for patients with established cardiovascular disease undergoing non-cardiac surgery, aspirin should be continued throughout the perioperative period without interruption 1, 2

Aspirin initiation should occur within 48 hours postoperatively to reduce saphenous vein graft closure, with dosing regimens of 100-325 mg daily appearing efficacious, according to the American Heart Association 1
The European Society of Cardiology recommends initiating aspirin post-operatively as soon as there is no concern over bleeding, without specifying an exact hour threshold 2
Doses higher than 162 mg/day can be continued for up to 1 year post-CABG, after which lower maintenance doses (75-162 mg daily) should be continued indefinitely, as suggested by the American College of Cardiology 1
The 2023 ACC/AHA performance measures emphasize that patients should either continue aspirin through the perioperative period OR be started on aspirin within 6 hours postoperatively if not previously taking it, according to the American College of Cardiology 3

Aspirin should be maintained throughout the perioperative period without interruption in patients with established coronary artery disease, prior myocardial infarction, or those requiring secondary cardiovascular prevention, as recommended by the European Society of Cardiology 5
The only exception is closed-space surgery (intracranial, spinal canal, or posterior chamber eye surgery), where aspirin should be stopped 7-10 days preoperatively, according to the American Heart Association 5

Aspirin must be maintained throughout the perioperative period whenever possible, as discontinuation significantly increases stent thrombosis risk, as stated by the American College of Cardiology 4, 5
For drug-eluting stents placed less than 6-12 months prior: maintain aspirin perioperatively; if dual antiplatelet therapy is needed, clopidogrel can be stopped 5 days before surgery and resumed postoperatively while aspirin continues, according to the European Society of Cardiology 4
Never substitute antiplatelet agents with heparin or low-molecular-weight heparin, as these do not adequately protect against stent thrombosis, as recommended by the American College of Cardiology 4, 5

Maintenance dose: 75-162 mg daily for long-term secondary prevention, as suggested by the American Heart Association 1
Higher initial doses (325 mg daily) may be used for 1-6 months after percutaneous coronary intervention with stent placement, depending on stent type, according to the American College of Cardiology 1
For patients with aspirin-exacerbated respiratory disease requiring desensitization: continued daily administration of at least 325 mg once daily is required to maintain tolerance; gaps >48 hours may lead to loss of tolerance, as stated by the American Academy of Allergy, Asthma, and Immunology 6, 7

Never discontinue both aspirin and clopidogrel simultaneously in patients with recent stent placement (within 6-12 months for drug-eluting stents or 4-6 weeks for bare-metal stents), as recommended by the American College of Cardiology 4, 5
Do not delay aspirin initiation beyond 48 hours after CABG, as this increases the risk of graft occlusion, according to the American Heart Association 1, 3
Avoid stopping aspirin in patients with established cardiovascular disease undergoing non-cardiac surgery unless the procedure involves a closed space where bleeding would be catastrophic, as stated by the European Society of Cardiology 5
For minor procedures (dental, dermatologic, cataract surgery), continue aspirin without interruption, according to the American College of Cardiology 5