How many days prior to surgery should Clopidogrel (Plavix) be stopped?

Clopidogrel (Plavix) Discontinuation Before Surgery

Clopidogrel should be discontinued 5-7 days before elective surgery to minimize bleeding risk, with the exact timing depending on the type of surgery and the patient's thrombotic risk. 1, 2

Recommended Discontinuation Timeline by Surgery Type

High Bleeding Risk Procedures

• Elective CABG/Cardiac Surgery: Stop clopidogrel 5-7 days before surgery 1, 2
• Neurosurgery/Intracranial Surgery: Stop clopidogrel 5 days before procedure 1
• Spinal Surgery: Stop clopidogrel 5 days before procedure 1
• Posterior Chamber Eye Surgery: Stop clopidogrel 5 days before procedure 1

Low Bleeding Risk Procedures

• Cataract Surgery: Clopidogrel can be continued 3
• Minor Dermatologic Procedures: Clopidogrel can be continued 3
• Dental Procedures: Clopidogrel can be continued 3

Special Considerations

Patients with Recent Coronary Stents

• Bare Metal Stents: If placed within 4-6 weeks, delay elective surgery if possible 1
• Drug-Eluting Stents: If placed within 6 months, delay elective surgery if possible 1
• Emergency Surgery: If surgery cannot be delayed, proceed with surgery while on clopidogrel with heightened awareness of bleeding risk 1

Urgent/Emergency Surgery

• For patients requiring urgent surgery who have taken clopidogrel within 5 days:
  • Consider plasma sequestration during surgery to reduce bleeding risk 4
  • Be prepared for potential increased blood product requirements 5
  • More urgent surgery may be performed by experienced surgeons if the incremental bleeding risk is considered acceptable 1

Resuming Clopidogrel Post-Surgery

• Resume clopidogrel as soon as hemostasis is achieved, typically within 24 hours after surgery 2, 6
• For high thrombotic risk patients, consider resuming within 12-24 hours post-operation 6
• Consider a loading dose (300-600 mg) if rapid platelet inhibition is needed for high-risk patients 3

Important Caveats

• Discontinuing clopidogrel increases the risk of cardiovascular events, especially in patients with recent stent placement 2
• The risk of coronary thrombosis after antiplatelet drug withdrawal may be higher than surgical bleeding risk in high-risk cardiac patients 7
• Recent evidence suggests that stopping clopidogrel just 3 days before CABG may not significantly increase bleeding compared to the standard 5-day discontinuation, though larger studies are needed 8

When making decisions about perioperative clopidogrel management, always weigh the thrombotic risk against bleeding risk, with special attention to patients with recent coronary interventions who are at highest risk for stent thrombosis if antiplatelet therapy is discontinued prematurely.