How long before surgery should Clopidogrel (antiplatelet agent) be stopped?

Perioperative Management of Clopidogrel Before Surgery

For most non-cardiac surgeries, clopidogrel should be discontinued at least 5 days before the procedure to minimize bleeding risk, while aspirin can typically be continued. 1

Timing of Clopidogrel Discontinuation by Surgery Type

Cardiac Surgery (CABG)

• Stop clopidogrel 5 days before elective CABG 1
• For urgent CABG, clopidogrel should be discontinued for at least 24 hours 1
• Aspirin should generally be continued perioperatively for CABG patients 1

Non-Cardiac Surgery

• High bleeding risk procedures (intracranial, spinal surgery, posterior chamber of eye):

  • Stop clopidogrel 5-7 days before surgery 1, 2
  • Consider stopping aspirin 5 days before procedure 1

• Intermediate bleeding risk procedures:

  • Stop clopidogrel 5 days before surgery 1
  • Continue aspirin if possible 1

• Low bleeding risk procedures (including most dental procedures):

  • Consider continuing both aspirin and clopidogrel 1, 3

Special Considerations

Patients with Recent Coronary Stents

• Drug-eluting stents: If possible, postpone elective surgery for 6 months to 1 year after stent placement 1
• Bare metal stents: If possible, postpone elective surgery for at least 4-6 weeks after stent placement 1
• For urgent/emergent surgery within these timeframes:
  • Consult with cardiology before modifying antiplatelet therapy 3
  • Consider maintaining aspirin even if clopidogrel must be discontinued 1, 3

Resumption of Therapy

• Resume clopidogrel as soon as hemostasis is achieved, ideally within 24 hours after surgery 1, 2
• Delayed resumption increases thrombotic risk 2
• Consider loading dose of 300 mg when restarting clopidogrel 1

Management of Bleeding Risk

• The FDA label for clopidogrel states: "When possible, interrupt therapy with clopidogrel for five days prior to surgery with a major risk of bleeding. Resume clopidogrel as soon as hemostasis is achieved." 2
• For procedures with high bleeding risk that cannot be delayed, consider:
  • Platelet transfusions for significant clinical bleeding (though effectiveness in reversing clopidogrel effect is uncertain) 1
  • Use of hemostatic agents like tranexamic acid 1

Important Caveats

• Recent research suggests that stopping clopidogrel 3 days before CABG may not significantly increase bleeding compared to 5 days 4, but current guidelines still recommend 5 days
• Some vascular surgeries may be safely performed without discontinuing clopidogrel 5, but this is not standard practice
• The risk of coronary thrombosis if antiplatelet drugs are withdrawn may outweigh the risk of surgical bleeding in high-risk cardiac patients 6
• Despite the common 7-day recommendation in some practices, one study showed that even after 7 days, patients previously on clopidogrel still had higher reoperation rates for bleeding 7

The decision to discontinue clopidogrel should balance bleeding risk against thrombotic risk, with particular caution in patients with recent stent placement. When in doubt, cardiology consultation is recommended, especially for high cardiac risk patients.