What are the perioperative guidelines for managing antiplatelet (e.g. aspirin, clopidogrel) and anticoagulant (e.g. warfarin, apixaban, rivaroxaban) agents?

Perioperative Management of Antiplatelet and Anticoagulant Therapy: Recent Updates

Antiplatelet Therapy Management

Aspirin

For patients at moderate to high cardiovascular risk undergoing noncardiac surgery, continue aspirin throughout the perioperative period rather than stopping it 7-10 days before surgery. 1

• Continue aspirin perioperatively for patients with coronary stents (regardless of type), prior myocardial infarction, or secondary cardiovascular prevention, as the thrombotic risk of discontinuation exceeds bleeding risk in most surgical settings 1, 2

• Stop aspirin 7-10 days preoperatively only in patients at low cardiovascular risk undergoing procedures where bleeding would occur in closed spaces (intracranial surgery, spinal canal surgery, posterior chamber eye surgery) 1

• For minor procedures (dental, dermatologic, cataract surgery), continue aspirin without interruption 1

Clopidogrel

Stop clopidogrel 5 days before elective surgery in patients without recent coronary stents, but maintain aspirin throughout the perioperative period. 3

• The 5-day discontinuation window allows adequate platelet function recovery while minimizing thrombotic risk 3

• Resume clopidogrel within 24 hours postoperatively once hemostasis is achieved; consider a 300 mg loading dose for high-risk patients 3

• For CABG surgery specifically: stop clopidogrel 5 days preoperatively but continue aspirin perioperatively 1, 3

Dual Antiplatelet Therapy (DAPT) in Patients with Coronary Stents

This is the highest-risk scenario requiring careful timing and risk stratification.

Timing of Elective Surgery Based on Stent Type:

• Drug-eluting stents (DES): Postpone elective surgery for at least 6-12 months after stent placement 1, 2

• Bare-metal stents (BMS): Postpone elective surgery for at least 4-6 weeks after stent placement 1, 2

If Surgery Cannot Be Delayed:

• Continue both aspirin and clopidogrel if surgery is within the critical timeframe and bleeding risk is minor 1, 2

• Maintain aspirin and stop clopidogrel 5 days preoperatively for intermediate or major bleeding risk procedures 2, 3

• Never stop both antiplatelet agents simultaneously in patients with recent stent placement, as this dramatically increases stent thrombosis risk with potentially fatal consequences 2, 3

Critical Warning:

Do not substitute antiplatelet therapy with heparin or low-molecular-weight heparin as "bridging therapy"—this does not protect against stent thrombosis and may increase bleeding risk. 3, 4

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Anticoagulant Therapy Management

Vitamin K Antagonists (Warfarin)

For patients at low thrombotic risk (mechanical heart valve, atrial fibrillation, or VTE at low risk), do not use bridging anticoagulation during warfarin interruption. 1

• Stop warfarin 5 days before surgery to allow INR normalization 1

• For minor procedures (dental, dermatologic, cataract), continue warfarin and optimize local hemostasis rather than interrupting therapy 1

• When bridging is necessary for high-risk patients, use therapeutic-dose subcutaneous LMWH or IV unfractionated heparin 1

Bridging Anticoagulation Protocols (When Required):

Therapeutic-dose subcutaneous LMWH:

• Administer last preoperative dose approximately 24 hours before surgery (not 12 hours) 1
• For high-bleeding-risk surgery, resume therapeutic-dose LMWH 48-72 hours postoperatively (not within 24 hours) 1

Therapeutic-dose IV unfractionated heparin:

• Stop UFH 4-6 hours before surgery 1

Direct Oral Anticoagulants (DOACs)

Apixaban should be discontinued at least 48 hours prior to elective surgery with moderate or high bleeding risk, or at least 24 hours prior to surgery with low bleeding risk. 5

• Bridging anticoagulation during the 24-48 hours after stopping apixaban is not generally required 5

• Restart apixaban after surgery as soon as adequate hemostasis has been established 5

• For rivaroxaban: stop 3 days preoperatively; for apixaban: stop 2 days preoperatively (though FDA labeling suggests 24-48 hours based on bleeding risk) 5, 6

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Surgery-Specific Bleeding Risk Categories

Minor Bleeding Risk:

• Continue both aspirin and clopidogrel if patient has coronary stent 3
• Continue warfarin with local hemostatic measures 1
• Examples: dental procedures, dermatologic procedures, cataract surgery 1

Intermediate Bleeding Risk:

• Continue aspirin, stop clopidogrel 5 days preoperatively 3
• Stop warfarin 5 days preoperatively 1

Major Bleeding Risk:

• Continue aspirin in stent patients whenever possible; stop clopidogrel 5 days preoperatively 3
• Stop warfarin 5 days preoperatively; consider bridging only for high thrombotic risk 1
• Stop DOACs 48 hours preoperatively 5

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Critical Pitfalls to Avoid

• Never discontinue both aspirin and clopidogrel simultaneously in patients with coronary stents placed within the past 6-12 months (DES) or 4-6 weeks (BMS) 2, 3

• Never use heparin or LMWH as a substitute for antiplatelet therapy in stent patients—it does not prevent stent thrombosis 3, 4

• Do not routinely bridge low-risk patients on warfarin—bridging increases bleeding without reducing thrombotic events 1

• Avoid vitamin K for routine warfarin reversal before elective surgery; simply stop warfarin 5 days preoperatively and allow natural INR decline 1