What medications should be held before surgery to minimize bleeding risk?

Medications to Hold Before Surgery to Minimize Bleeding Risk

For most surgeries, aspirin can be continued perioperatively, but P2Y12 inhibitors (clopidogrel, ticagrelor, prasugrel) must be stopped 5-7 days before elective procedures, with specific timing based on the agent and bleeding risk of the surgery. 1, 2

Antiplatelet Agents

Aspirin

• Continue aspirin (75-325 mg daily) through the perioperative period for most surgeries, including cardiac procedures like CABG 1, 3
• Stop aspirin only for high bleeding-risk surgeries (neurosurgery, spinal canal surgery, posterior chamber eye surgery) where bleeding occurs in closed spaces—discontinue 5 days preoperatively 3, 4
• For standard surgeries, stopping aspirin 3 days before is sufficient if discontinuation is deemed necessary 3
• Resume aspirin 12-24 hours postoperatively when hemostasis is achieved 3

P2Y12 Inhibitors (Clopidogrel, Ticagrelor, Prasugrel)

Elective Surgery:

• Clopidogrel: Stop 5 days before surgery 1, 5
• Ticagrelor: Stop 3-5 days before surgery (5 days for CABG specifically) 1, 2
• Prasugrel: Stop 7 days before surgery 1

Urgent Surgery:

• Clopidogrel and ticagrelor can be stopped 24 hours before urgent procedures with acceptable major bleeding risk, though blood transfusions may increase 1
• Resume P2Y12 inhibitors as soon as possible postoperatively, ideally within 12-24 hours when hemostasis permits 1, 5

Critical Timing Considerations for Patients with Coronary Stents

• Delay elective surgery for at least 1 month after bare-metal stent (BMS) placement 1
• Delay elective surgery for at least 6 months after drug-eluting stent (DES) placement 1
• If surgery cannot be delayed and dual antiplatelet therapy (DAPT) must be interrupted, continue aspirin and stop only the P2Y12 inhibitor, restarting it within 5 days postoperatively 1
• Never stop both antiplatelet agents simultaneously in stent patients unless bleeding risk is life-threatening 1

Glycoprotein IIb/IIIa Inhibitors

• Eptifibatide and tirofiban: Stop 2-4 hours before surgery 1
• Abciximab: Stop 12 hours before surgery 1

Anticoagulants

Warfarin

• Stop warfarin 4-5 days before surgery to allow INR to normalize (target INR <1.5) 1
• For low thrombotic risk patients (atrial fibrillation without prior stroke, >3 months from venous thromboembolism), no bridging therapy is needed 1
• For high thrombotic risk patients (mechanical mitral valve, recent thromboembolism, ball/cage valve), bridge with therapeutic-dose heparin or LMWH when INR falls below therapeutic range 1
• Stop heparin 5 hours before surgery or LMWH 12-24 hours before surgery 1
• Resume warfarin 12-24 hours postoperatively when bleeding risk is acceptable 1

Novel Oral Anticoagulants (NOACs)

• Apixaban: Stop 2 days before surgery 6
• Rivaroxaban: Stop 3 days before surgery 1, 6
• Dabigatran: Stop 2-5 days before surgery depending on renal function and bleeding risk 1
• For minor bleeding-risk procedures, NOACs do not require modification 1

Surgery-Specific Bleeding Risk Stratification

High Bleeding Risk (Stop All Antiplatelet/Anticoagulant Agents)

• Intracranial neurosurgery 3, 4
• Spinal canal surgery 3, 4
• Posterior chamber eye surgery 1, 4
• Procedures where bleeding cannot be easily controlled 1

Moderate Bleeding Risk (Continue Aspirin, Stop P2Y12 Inhibitors)

• Coronary artery bypass grafting 1
• Major abdominal surgery 4
• Urological procedures 1

Low Bleeding Risk (Continue All Antiplatelet Agents)

• Dental procedures 1
• Upper endoscopy with biopsy 7
• Colonoscopy with biopsy 7
• Most minor surgical procedures 4

NSAIDs and Bleeding Risk

• Stop NSAIDs 1-10 days before surgery depending on the specific agent's half-life 6:
  • Short-acting (1 day): Ibuprofen, ketorolac, diclofenac 6
  • Intermediate (2-4 days): Indomethacin, naproxen, meloxicam 6
  • Long-acting (6-10 days): Oxaprozin, piroxicam 6
• NSAIDs significantly increase bleeding risk when combined with anticoagulants or antiplatelet agents 6

Critical Pitfalls to Avoid

Do not use heparin bridging as a substitute for antiplatelet therapy in stent patients—it does not prevent stent thrombosis 4

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

Multidisciplinary consultation with cardiology is mandatory when urgent surgery is required within 6 months of DES placement or 1 month of BMS placement 1

Platelet transfusions are ineffective if given within 4 hours of a P2Y12 inhibitor loading dose or 2 hours of maintenance dose 5