How long should a patient be off Plavix (clopidogrel) prior to Coronary Artery Bypass Grafting (CABG)?

Clopidogrel Discontinuation Before CABG Surgery

For elective CABG surgery, clopidogrel (Plavix) should be discontinued for at least 5 days prior to surgery to limit bleeding complications and blood transfusion requirements. 1

Timing of Clopidogrel Discontinuation Based on Urgency

Elective CABG

• Discontinue clopidogrel at least 5 days before surgery to minimize bleeding risk and transfusion requirements 1
• The FDA label for clopidogrel recommends interrupting therapy for five days prior to surgery with major bleeding risk 2
• Platelet function takes approximately 5 days to normalize after clopidogrel discontinuation due to its irreversible inhibition of platelet aggregation 2

Urgent CABG

• Discontinue clopidogrel for at least 24 hours before surgery to reduce major bleeding complications 1
• In urgent cases where surgery cannot be delayed for 5 days, proceeding with CABG after at least 24 hours of clopidogrel discontinuation is reasonable, though it carries increased bleeding risk 1
• Blood transfusion requirements are likely to be higher when CABG is performed 1-4 days after clopidogrel discontinuation 1

Evidence on Bleeding Risk

• Patients who undergo CABG within 5 days of clopidogrel exposure have:

  • Significantly increased chest tube drainage (1485 ml vs 780 ml in controls) 3
  • Higher reoperation rates for bleeding (5.9% vs 1.2%) 3
  • Increased need for blood product transfusions 4, 5

• Patients who undergo CABG within 3 days of clopidogrel exposure have:

  • Higher blood transfusion requirements compared to those who discontinued clopidogrel >3 days before surgery 5
  • Almost twice the reoperation rate compared to patients not taking clopidogrel 5

• Mortality risk may be highest when clopidogrel is given within 48 hours of surgery 6

Comparison with Other Antiplatelet Agents

• Prasugrel requires a longer discontinuation period of at least 7 days before elective CABG 1
• Ticagrelor should be discontinued for at least 5 days before elective CABG, similar to clopidogrel 1
• For urgent CABG, both ticagrelor and clopidogrel should be discontinued for at least 24 hours 1

Resumption of Antiplatelet Therapy

• Resume clopidogrel as soon as hemostasis is achieved, typically within 24 hours after CABG 1, 2
• Early resumption of antiplatelet therapy is important to prevent graft occlusion and adverse cardiovascular events 1

Clinical Pitfalls and Caveats

• Discontinuing clopidogrel increases the risk of cardiovascular events, especially in patients with recent stent placement 2
• For patients with high thrombotic risk (recent stent placement, acute coronary syndrome), the decision to discontinue clopidogrel should balance bleeding risk against thrombotic risk 1
• In patients referred for urgent CABG who cannot wait 5 days, aggressive correction of platelet dysfunction may be required before chest closure 3
• Platelet transfusions may help restore hemostasis, but they are less effective if given within 4 hours of a loading dose or 2 hours of a maintenance dose of clopidogrel 2