How many days prior to major surgery should aspirin and clopidogrel (Plavix) be withheld?

Perioperative Management of Aspirin and Clopidogrel Before Major Surgery

For major surgery, clopidogrel should be discontinued at least 5 days before surgery, while aspirin may be continued throughout the perioperative period unless the surgery involves a closed space or has high bleeding risk. 1

Specific Timing Recommendations

Clopidogrel (Plavix)

• Discontinue clopidogrel at least 5 days before elective major surgery 1
• For urgent surgeries, clopidogrel should be discontinued for at least 24 hours to reduce major bleeding risk 1
• P2Y12 inhibitors (including clopidogrel) inhibit platelet aggregation for the lifetime of the platelet (7-10 days) 2
• Clopidogrel's FDA label specifically states: "When possible, interrupt therapy with clopidogrel for five days prior to surgery with a major risk of bleeding" 2

Aspirin

• Aspirin can generally be continued throughout the perioperative period for most major surgeries 1
• Exception: Discontinue aspirin for surgeries involving closed spaces (neurosurgery, spinal surgery, posterior chamber eye surgery) or with expected excessive blood loss 1, 3
• If aspirin must be discontinued, it should be stopped 5-7 days before surgery 4

Risk Stratification Approach

High Thrombotic Risk Patients

• For patients with recent coronary stent placement:
  • Elective surgery should be delayed when possible: at least 6 weeks after bare metal stent and 6 months after drug-eluting stent 5
  • For urgent surgery in high thrombotic risk patients, cardiology consultation is recommended 5

Bleeding Risk Considerations

• The risk of surgical bleeding if antiplatelet drugs are continued is generally lower than the risk of coronary thrombosis if they are withdrawn 3
• For most surgical procedures, aspirin can be safely continued 3, 4
• Combined therapy with clopidogrel and aspirin up to the day of surgery has not been associated with increased bleeding complications in peripheral arterial surgery 6

Resumption of Therapy

• Resume clopidogrel as soon as hemostasis is achieved, typically within 24 hours after surgery 2
• Some experts recommend a loading dose of at least 300 mg of clopidogrel when treatment is resumed 1

Important Caveats

• Platelet transfusions may restore hemostasis if needed, but may be less effective if given within 4 hours of clopidogrel loading dose 2
• Substitution with heparin or low-molecular weight heparin does not provide adequate protection against stent thrombosis 3
• For coronary artery bypass graft (CABG) surgery specifically, clopidogrel and ticagrelor should be discontinued for at least 5 days, and prasugrel for at least 7 days 1
• Discontinuation of clopidogrel increases the risk of cardiovascular events, so the drug should be restarted as soon as possible 2

The decision to continue or discontinue antiplatelet therapy must balance the risk of perioperative bleeding against the risk of thrombotic events, with the understanding that the consequences of stent thrombosis are generally more serious than those of bleeding complications, except in cases of intracranial surgery 7.