Should Plavix (clopidogrel) be discontinued prior to surgery?

Perioperative Management of Clopidogrel (Plavix)

Clopidogrel (Plavix) should be discontinued 5 days before elective surgery to minimize bleeding risk while allowing adequate time for platelet function recovery. 1, 2

General Recommendations for Discontinuation

• Clopidogrel irreversibly inhibits platelets for their entire lifespan (7-10 days), requiring 5-7 days for adequate recovery of platelet function before surgery 2
• The American College of Cardiology/American Heart Association guidelines specifically recommend discontinuing clopidogrel 5 days before elective surgery 1
• FDA labeling for clopidogrel states: "When possible, interrupt therapy with clopidogrel for five days prior to surgery" 2
• Different P2Y12 inhibitors require different discontinuation timeframes: clopidogrel (5 days), ticagrelor (3-5 days), and prasugrel (7 days) 1

Surgery-Specific Considerations

• For most surgical procedures, clopidogrel should be discontinued 5 days preoperatively 3
• For surgeries with particularly high bleeding risk or procedures in confined spaces (brain, posterior chamber of the eye, spinal canal), both aspirin and clopidogrel should be discontinued 3, 4
• For coronary artery bypass grafting (CABG), guidelines specifically recommend discontinuing clopidogrel 5-7 days before elective surgery 3
• For urgent CABG, clopidogrel should be discontinued for at least 24 hours before surgery to reduce major bleeding complications 1

Risk Stratification Approach

• For patients with coronary stents placed within the last 6-12 weeks, the thrombotic risk of discontinuation may outweigh bleeding risk 1
• For drug-eluting stents, elective surgery should ideally be postponed for at least 6 months after placement 1
• For patients at high risk of thrombosis, consultation with cardiology before discontinuing clopidogrel is recommended 4

Management of Urgent/Emergent Surgery

• If surgery cannot be delayed, be prepared for increased bleeding risk 5, 6
• In emergency situations requiring immediate surgery, consider platelet transfusions to restore hemostasis 2, 6
• Platelet transfusions within 4 hours of loading dose or 2 hours of maintenance dose may be less effective 2
• For CABG specifically, some evidence suggests that discontinuation 3 days prior to surgery may be acceptable with similar hemoglobin drops compared to 5-day discontinuation 7

Resumption of Antiplatelet Therapy

• Clopidogrel should be resumed as soon as hemostasis is achieved, typically within 24 hours after surgery 2, 8
• Early resumption (within 24 hours) rather than delayed resumption reduces thrombotic risk 1

Important Caveats

• Discontinuation of clopidogrel increases the risk of cardiovascular events, particularly in patients with recent stent placement 2, 8
• The decision to discontinue clopidogrel must balance bleeding risk against thrombotic risk 4, 5
• Unlike aspirin, which can be continued for many procedures, clopidogrel carries a higher bleeding risk and should generally be discontinued 3, 4
• Substituting heparin or low-molecular-weight heparin does not provide adequate protection against stent thrombosis 8

Emerging Approaches

• Platelet function testing to guide timing of surgery is an emerging approach but is not currently recommended routinely 3, 1
• For unavoidable urgent cardiac surgery, techniques like plasma sequestration may help reduce bleeding complications in patients who have taken clopidogrel within 1-4 days of surgery 9