When should antiplatelet (e.g. aspirin) and anticoagulant (e.g. warfarin) medications be held before surgery?

When to Hold Antiplatelet and Anticoagulant Medications Before Surgery

For most surgeries, aspirin should be continued perioperatively and only discontinued 5 days before procedures with exceptionally high bleeding risk (intracranial, spinal canal, or posterior eye chamber surgery), while P2Y12 inhibitors should be stopped 3-7 days preoperatively depending on the specific agent, and warfarin should be discontinued 5 days before surgery. 1, 2

Antiplatelet Medications

Aspirin

• Continue aspirin through the perioperative period for most surgeries, as bleeding risk does not outweigh thrombotic risk 1
• Discontinue aspirin 5 days before surgery only for procedures where even minor bleeding is catastrophic: 1
  • Intracranial neurosurgery
  • Spinal surgery within the medullary canal
  • Posterior chamber eye surgery
• Resume aspirin 12-24 hours after surgery once adequate hemostasis is achieved 1, 2

P2Y12 Inhibitors (Clopidogrel, Prasugrel, Ticagrelor)

The discontinuation timeline varies by agent due to different pharmacokinetics: 1

• Ticagrelor: Stop at least 3 days before surgery 1, 2
• Clopidogrel: Stop 5 days before surgery 1, 2
• Prasugrel: Stop 7 days before surgery 1, 2

Critical caveat: In patients with drug-eluting stents (DES) or recent acute coronary syndrome (ACS), the thrombotic risk of stopping P2Y12 inhibitors is substantially higher than surgical bleeding risk—elective surgery should be postponed until at least 6-12 months after stent placement or ACS if dual antiplatelet therapy (DAPT) must be interrupted 1

Special Considerations for Coronary Stents

High-risk patients requiring continued DAPT: 1

• Bare metal stent (BMS): Surgery requiring DAPT interruption should be delayed at least 4 weeks (ideally 3 months)
• Drug-eluting stent (DES): Surgery requiring DAPT interruption should be delayed at least 6-12 months
• Recent MI or ACS: Surgery should be postponed at least 6 months if possible

If surgery cannot be delayed in stented patients: 1

• For very low bleeding-risk procedures: Continue both aspirin and P2Y12 inhibitor
• For low-to-intermediate bleeding risk: Stop P2Y12 inhibitor 5-7 days preoperatively but maintain aspirin throughout
• For high bleeding risk (only when bleeding risk clearly outweighs thrombotic risk): Stop both agents 5 days before surgery, but restart within 24-48 hours postoperatively

The median time to stent thrombosis is 7 days when both agents are stopped versus 122 days when only the P2Y12 inhibitor is stopped while maintaining aspirin—this dramatic difference underscores the critical importance of continuing aspirin whenever possible 1

Anticoagulant Medications

Warfarin

• Discontinue 5 days before surgery to allow INR normalization 2, 3
• Check PT/INR immediately before surgery to confirm normalization 3
• For emergency surgery within 6-8 hours: Give 5 mg intravenous vitamin K (phytomenadione), though this may preclude re-warfarinization for several days 1
• For immediate emergency surgery: Reverse with prothrombin complex concentrate (PCC) 25-50 IU/kg 1

Direct Oral Anticoagulants (DOACs)

• Discontinue 2-5 days before surgery depending on renal function and specific DOAC 2
• Dabigatran can be rapidly reversed with idarucizumab if emergency surgery is required 1
• Factor Xa inhibitors (rivaroxaban, apixaban, edoxaban) can be reversed with andexanet alfa for severe bleeding, though this should not be used when some anticoagulation is required (e.g., cardiac or vascular surgery requiring bypass) 1

Bridging Anticoagulation

Bridging with therapeutic-dose LMWH or heparin is indicated only in specific high-risk scenarios: 1

When to Bridge:

• Acute VTE within the past 3 months: Bridging should be considered due to very high recurrence risk 1
• Atrial fibrillation with CHA₂DS₂-VASc score >4 AND recent stroke/TIA within 3 months: Consider bridging 1
• Atrial fibrillation with previous stroke/TIA plus ≥3 additional risk factors: Consider bridging 1

When NOT to Bridge:

• VTE >3 months ago: Use only prophylactic-dose LMWH postoperatively 1
• Atrial fibrillation with CHA₂DS₂-VASc ≤4 without recent stroke/TIA: Do not bridge 1

Critical pitfall: Bridging with heparin when stopping aspirin increases bleeding risk without clear thrombotic benefit and should be avoided 4

Common Pitfalls to Avoid

1. Never stop aspirin in patients with coronary stents placed within 6-12 months without cardiology consultation—the thrombotic risk is prohibitive 1, 4

2. Do not routinely discontinue aspirin for dental procedures or minor surgeries—local hemostatic measures are sufficient, and thrombotic risk outweighs bleeding risk 4

3. Do not assume all antiplatelet agents have the same discontinuation timeline—ticagrelor requires only 3 days while prasugrel requires 7 days due to different pharmacokinetics 1, 2

4. Restart antiplatelet therapy as soon as hemostasis is achieved (typically 12-24 hours postoperatively)—prolonged interruption dramatically increases thrombotic risk 1, 2, 4

5. Perform thorough medication reconciliation—patients often fail to report over-the-counter NSAIDs with antiplatelet effects 2

6. Recognize that bleeding risk increases exponentially when multiple antiplatelet or anticoagulant medications are combined—this requires heightened vigilance 2