Clopidogrel (Plavix) Discontinuation Before Surgery
For elective surgery, clopidogrel (Plavix) should be discontinued at least 5 days before the procedure to reduce the risk of major bleeding complications. 1, 2
Timing of Clopidogrel Discontinuation Based on Surgery Type
Elective Surgery
- Standard recommendation: Discontinue clopidogrel 5 days before surgery 1
- High bleeding risk procedures (neurosurgery, spinal surgery, posterior chamber eye surgery): 5-7 days before surgery 1
Urgent/Emergency Surgery
- Minimum discontinuation: At least 24 hours before surgery to reduce major bleeding 1
- If surgery cannot be delayed: Consider proceeding with surgery with awareness of increased bleeding risk 1
Special Considerations Based on Cardiac Risk
Patients with Coronary Stents
- Bare metal stents: Defer elective surgery for at least 6 weeks after placement 1
- Drug-eluting stents: Defer elective surgery for at least 6 months after placement 1
- If surgery cannot be delayed: Consider continuing dual antiplatelet therapy perioperatively despite increased bleeding risk 1
Coronary Artery Bypass Grafting (CABG)
- Elective CABG: Discontinue clopidogrel 5 days before surgery 1
- Urgent CABG: Discontinue clopidogrel at least 24 hours before surgery 1
Perioperative Management Strategies
For High Thrombotic Risk Patients Requiring Early Surgery
- Consider bridging with intravenous glycoprotein IIb/IIIa inhibitors (eptifibatide or tirofiban) 3
- Discontinue these agents 2-4 hours before surgery 1
Resumption After Surgery
- Resume clopidogrel as soon as hemostasis is achieved 2
- For patients at high risk of stent thrombosis, resume within 12-24 hours post-operation 4
Important Caveats
- Aspirin management: In many cases, aspirin can be continued perioperatively, especially for cardiac procedures 1
- Platelet function: Clopidogrel inhibits platelet aggregation for the lifetime of the platelet (7-10 days) 2
- Bleeding risk factors: Consider patient-specific factors that may increase bleeding risk (renal dysfunction, advanced age, concomitant anticoagulants) 2
- Thrombotic risk: The risk of stent thrombosis with premature discontinuation may outweigh bleeding risk in high-risk patients 1
While some recent research suggests that discontinuing clopidogrel 3 days before CABG might not significantly increase bleeding compared to 5 days 5, the most current guidelines still recommend the 5-day washout period for elective procedures to optimize the balance between bleeding and thrombotic risks.