How long should Plavix (clopidogrel) be held before surgery?

Perioperative Management of Clopidogrel (Plavix) for Surgery

For elective surgery, clopidogrel (Plavix) should be discontinued 5 days before the procedure to minimize bleeding risk while balancing thrombotic concerns. 1

General Recommendations for Clopidogrel Discontinuation

The timing of clopidogrel discontinuation depends on the type of surgery and patient's thrombotic risk:

• Standard elective surgery: Stop clopidogrel 5 days before surgery 1
• Cardiac surgery (CABG): Stop clopidogrel 5 days before elective CABG 1
• High bleeding risk procedures:
  • Neurosurgery, spinal surgery, posterior chamber eye surgery: Stop clopidogrel 7 days before surgery 1
  • For surgeries in closed spaces where bleeding consequences are severe, longer discontinuation may be necessary

Special Considerations

Coronary Stent Patients

For patients with recent coronary stent placement, management requires careful consideration:

• Drug-eluting stents: If placed within 6 months, consider delaying elective surgery 1
• Bare metal stents: If placed within 4-6 weeks, consider delaying elective surgery 1
• Urgent/emergent surgery: If surgery cannot be delayed, consider:
  • Continuing aspirin throughout the perioperative period 1
  • Consulting cardiology for risk assessment
  • For very high-risk patients (recent stent placement), bridging therapy with intravenous glycoprotein IIb/IIIa inhibitors may be considered in specialized centers 2

Resumption of Therapy

• Resume clopidogrel within 24 hours after surgery if hemostasis is adequate 1
• For high bleeding risk procedures, resumption may be delayed based on postoperative bleeding risk assessment

Risk Stratification Algorithm

1. High thrombotic risk (recent stent placement, acute coronary syndrome within 3 months):

   • Delay elective surgery if possible
   • If surgery cannot be delayed, maintain aspirin and consult cardiology

2. Moderate thrombotic risk (stable coronary disease on dual antiplatelet therapy):

   • Stop clopidogrel 5 days before surgery
   • Consider continuing aspirin throughout perioperative period

3. Low thrombotic risk (primary prevention or >1 year after coronary event):

   • Stop clopidogrel 5 days before surgery
   • Resume within 24 hours postoperatively

Common Pitfalls to Avoid

1. Excessive discontinuation time: Stopping clopidogrel for >5 days increases thrombotic risk unnecessarily. Recent evidence suggests that 5 days is sufficient for most surgeries 1, 3

2. Bridging with heparin: Heparin or low-molecular-weight heparin does not provide adequate protection against stent thrombosis when clopidogrel is discontinued 4

3. Inadequate communication: Failure to coordinate between surgical and cardiology teams can lead to suboptimal management

4. One-size-fits-all approach: The 5-day recommendation may need adjustment based on specific surgical bleeding risk and patient thrombotic risk

Recent research suggests that for some procedures, a shorter discontinuation period (3 days) might be sufficient 3, but the most current guidelines still recommend 5 days for most elective surgeries to optimize the balance between bleeding and thrombotic risks 1.