Should you hold Plavix (clopidogrel) pre-operatively?

Perioperative Management of Clopidogrel (Plavix)

For patients undergoing elective surgery who are taking clopidogrel, you should discontinue clopidogrel 5 days before surgery to minimize bleeding risk while allowing adequate time for platelet function recovery. 1

General Recommendations for Clopidogrel Discontinuation

• Clopidogrel should be discontinued 5 days before elective surgery according to the American College of Cardiology/American Heart Association guidelines 1
• P2Y12 inhibitors like clopidogrel irreversibly inhibit platelet aggregation for the lifetime of the platelet (7-10 days), requiring adequate time for new platelet production before surgery 2
• Discontinuation timing should be based on the type of P2Y12 inhibitor:
  • Clopidogrel: 5 days before surgery 1
  • Ticagrelor: 3-5 days before surgery 1
  • Prasugrel: 7 days before surgery 1

Surgery-Specific Considerations

• For patients undergoing CABG surgery specifically, the American College of Chest Physicians recommends interruption of P2Y12 inhibitors over continuation perioperatively 1
• For urgent CABG, clopidogrel should be discontinued for at least 24 hours before surgery to reduce major bleeding complications 1
• For non-cardiac surgery, continuing clopidogrel is associated with increased blood loss, transfusion requirements, and reoperation for bleeding 3

Risk Stratification Approach

• High thrombotic risk patients (recent coronary stent placement):

  • For patients with coronary stents placed within the last 6-12 weeks, consider either continuation of dual antiplatelet therapy or stopping only one agent 1
  • For drug-eluting stents, elective surgery should ideally be postponed for at least 6 months after placement 4, 5
  • For bare metal stents, elective surgery should be postponed for at least 4-6 weeks 4, 5

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

  • These procedures require complete discontinuation of clopidogrel due to risk of bleeding in closed spaces 5

Resumption of Antiplatelet Therapy

• Antiplatelet drugs should be resumed within 24 hours after surgery rather than later to reduce thrombotic risk 1
• For CABG specifically, P2Y12 inhibitors should be resumed within 24 hours after surgery 1
• Early resumption must be balanced against the risk of postoperative bleeding 2

Important Caveats and Pitfalls

• Discontinuing clopidogrel increases the risk of cardiovascular events, especially in patients with recent stent placement 2
• The risk of surgical bleeding if antiplatelet drugs are continued is generally lower than the risk of coronary thrombosis if they are withdrawn, except in closed-space surgeries 5
• Recent research suggests that discontinuing clopidogrel 3 days before CABG may be as safe as 5 days in terms of bleeding risk, which could be considered for high thrombotic risk patients 6
• For non-elective orthopedic surgery, proceeding with surgery without delay appears to be safe even for patients on clopidogrel 7

Special Considerations

• Platelet transfusions may be considered to restore hemostasis in emergency situations, as the effects of clopidogrel are not reversible by other drugs 2, 5
• Bridging with intravenous glycoprotein IIb/IIIa inhibitors (e.g., eptifibatide) may be considered for high-risk patients requiring temporary discontinuation of clopidogrel 8
• Routine use of platelet function testing prior to surgery is not recommended to guide perioperative antiplatelet management 1

Remember that the decision to discontinue clopidogrel must always balance the risk of bleeding against the risk of thrombotic events, with cardiology consultation recommended for high-risk patients 4, 2.