When to stop antiplatelet agents (e.g. clopidogrel, ticagrelor) and statins, and when to start and stop Clexane (enoxaparin) in a patient planned for Coronary Artery Bypass Grafting (CABG) in 2 days?

Perioperative Management of Antiplatelet Agents and Anticoagulation for CABG in 2 Days

For a patient scheduled for CABG in 2 days, continue aspirin through surgery, stop clopidogrel immediately (ideally 5 days before but accept the increased bleeding risk given the 2-day timeline), stop ticagrelor immediately (ideally 5 days before), stop prasugrel immediately (ideally 7 days before), discontinue enoxaparin 12-24 hours before surgery and bridge with unfractionated heparin, and never stop statins perioperatively. 1

Antiplatelet Management

Aspirin

• Continue aspirin (81-325 mg daily) through surgery without interruption 1
• Aspirin reduces perioperative myocardial infarction, acute renal injury, and mortality without significantly increasing bleeding risk in CABG patients 1
• This is a Class I, Level of Evidence A recommendation 1

P2Y12 Inhibitors (Clopidogrel, Ticagrelor, Prasugrel)

Ideal timing (elective surgery):

• Clopidogrel: discontinue 5-7 days before CABG 1, 2
• Ticagrelor: discontinue at least 5 days before CABG 1, 3
• Prasugrel: discontinue at least 7 days before CABG 1, 3

Your patient's situation (2 days until surgery):

• With only 2 days available, stop the P2Y12 inhibitor immediately 1
• For urgent CABG, discontinuing clopidogrel or ticagrelor at least 24 hours before surgery reduces major bleeding complications (Class I, Level B) 1
• Expect increased bleeding risk: patients on clopidogrel <5 days before surgery have higher rates of major bleeding (9.6% vs 6.3%) and reoperation for bleeding 2
• Surgery can proceed if the incremental bleeding risk is considered acceptable by experienced surgeons (Class I, Level C) 1

Critical caveat: The risk-benefit calculation depends on why surgery cannot be delayed. If this is truly urgent CABG (e.g., ongoing ischemia, left main disease, unstable anatomy), the thrombotic risk of delaying surgery outweighs the bleeding risk of proceeding early 4

Enoxaparin (Clexane) Management

Discontinue enoxaparin 12-24 hours before CABG and transition to unfractionated heparin per institutional practice (Class I, Level B) 1

Practical algorithm:

• If surgery is in 48 hours: give last dose of enoxaparin now, then switch to UFH infusion 24 hours before surgery
• If surgery is in 24-36 hours: stop enoxaparin immediately and start UFH infusion
• Continue UFH infusion until surgery 1
• UFH can be discontinued 4 hours before surgery or continued based on institutional protocols 1

Statin Management

Never discontinue statins perioperatively - this question contains a common misconception. Statins should be:

• Continued through surgery without interruption
• Statins reduce perioperative cardiovascular events and have no contraindication for CABG
• There is no guideline recommendation to stop statins before cardiac surgery

Postoperative Resumption

Resume antiplatelet therapy as soon as hemostasis is achieved, typically within 24 hours after surgery 3, 5

• Aspirin: continue immediately postoperatively 1
• P2Y12 inhibitor: resume within 12-24 hours post-CABG unless contraindicated by excessive bleeding or thrombocytopenia (platelet count <50,000) 2, 3, 4
• For patients with recent ACS or coronary stents, resuming dual antiplatelet therapy for 12 months postoperatively reduces subsequent cardiovascular events 6
• A loading dose of clopidogrel (300-600 mg) can achieve maximal effect within 12-15 hours if rapid antiplatelet effect is needed 3

Key Pitfalls to Avoid

• Do not bridge P2Y12 inhibitors with cangrelor, GP IIb/IIIa inhibitors, or LMWH - these do not protect against stent thrombosis and may increase bleeding 3, 4
• Do not use platelet function testing to guide perioperative management - it does not improve outcomes 3
• Do not stop statins - there is no indication for this and it may increase perioperative cardiovascular risk
• Do not delay resumption of antiplatelet therapy postoperatively - the thrombotic risk increases significantly with each day of delay 3, 5

Special Consideration for Your 2-Day Timeline

Given the suboptimal 2-day window, ensure the surgical team is aware of recent P2Y12 inhibitor use 1. Have platelets available in the operating room, as platelet transfusion may be needed (incidence 13.5% with recent ticagrelor use vs 6.0% with aspirin alone) 7. Fresh platelets are the only way to rapidly restore hemostasis when antiplatelet effects are not fully dissipated 4.