What medications, such as warfarin (anticoagulant), aspirin (acetylsalicylic acid), and clopidogrel (antiplatelet), should be held prior to surgery to minimize bleeding risk?

Preoperative Medication Management to Minimize Bleeding Risk

For most surgeries, continue aspirin throughout the perioperative period, discontinue clopidogrel and ticagrelor 5 days before surgery, and discontinue prasugrel 7 days before surgery. 1, 2

Antiplatelet Agent Management

Aspirin

• Continue aspirin (75-325 mg daily) throughout the perioperative period for most surgeries, including cardiac procedures, as the cardiovascular protection outweighs bleeding risk 3, 2, 4
• Discontinue aspirin only for surgeries in closed spaces (intracranial surgery, spinal canal procedures, posterior chamber eye surgery) or procedures with expected excessive blood loss 1, 4, 5
• For high-bleeding-risk surgeries requiring aspirin discontinuation, stop 5 days preoperatively 4
• Resume aspirin 12-24 hours postoperatively once adequate hemostasis is achieved 4

Clopidogrel

• Discontinue clopidogrel at least 5 days before elective major surgery to allow replacement of approximately half the platelet pool 3, 1, 6
• For urgent surgery when 5-day discontinuation is not feasible, stop clopidogrel at least 24 hours before the procedure to reduce major bleeding risk 1, 2
• Resume clopidogrel as soon as hemostasis is achieved, ideally within 12-24 hours postoperatively 6, 5
• Consider a loading dose of 300-600 mg when resuming therapy 1, 6

Ticagrelor

• Discontinue ticagrelor at least 5 days before elective surgery 3, 1
• For urgent procedures, discontinue at least 24 hours preoperatively 2
• Ticagrelor continuation before surgery increases major bleeding complications similar to other P2Y12 inhibitors 3

Prasugrel

• Discontinue prasugrel at least 7 days before elective surgery due to its more potent and prolonged antiplatelet effects 3, 1
• For urgent surgery, discontinue at least 24 hours preoperatively 2
• Prasugrel carries higher bleeding risk than clopidogrel, with increased rates of major bleeding, platelet transfusions, and surgical re-explorations 3

Anticoagulant Management

Warfarin

• Discontinue warfarin preoperatively with timing based on INR normalization (typically 5 days) 7
• Do not routinely bridge with heparin or low-molecular-weight heparin unless patient has high thrombotic risk, as bridging increases bleeding without clear cardiovascular protection 3, 5
• Use vitamin K subcutaneously only for urgent/emergency surgery requiring rapid reversal 8

Low-Molecular-Weight Heparin (LMWH)

• For patients on enoxaparin, discontinue 12-24 hours before surgery 2
• Transition to unfractionated heparin during washout period only if thrombotic protection is essential 2

Special Populations and Situations

Patients with Coronary Stents

• Delay elective surgery when possible: minimum 6 weeks after bare metal stent, 6 months after drug-eluting stent 1
• For urgent surgery in stented patients, obtain cardiology consultation to assess thrombotic risk 1
• In patients requiring urgent cardiac surgery after recent stent placement, the thrombotic risk of discontinuing dual antiplatelet therapy often exceeds surgical bleeding risk 5

Coronary Artery Bypass Graft (CABG) Surgery

• Continue aspirin throughout CABG surgery as it reduces operative morbidity and mortality with only modest bleeding increase 3, 2
• Discontinue clopidogrel and ticagrelor 5 days before elective CABG 3, 2
• Discontinue prasugrel 7 days before elective CABG 3, 2
• For urgent CABG, discontinue P2Y12 inhibitors at least 24 hours preoperatively if feasible 2

Dual Antiplatelet Therapy (DAPT)

• For patients on DAPT, continue aspirin and discontinue only the P2Y12 inhibitor according to the timelines above 3, 1
• Never discontinue both agents simultaneously in high-risk patients (recent acute coronary syndrome, recent stent) unless bleeding risk is life-threatening 3, 5

Critical Pitfalls to Avoid

• Do not substitute heparin or LMWH for antiplatelet therapy as "bridging"—this does not protect against coronary or stent thrombosis and increases bleeding risk 3, 5
• Do not transfuse platelets prophylactically; reserve platelet transfusion only for patients with active abnormal bleeding attributed to antiplatelet effects 8, 9
• Platelet transfusions within 4 hours of clopidogrel loading dose or 2 hours of maintenance dose may be less effective 6
• Do not delay urgent/emergent surgery solely to allow complete platelet recovery—the thrombotic risk of the underlying condition often outweighs surgical bleeding risk 5, 8

Resumption Strategy

• Restart antiplatelet therapy as soon as adequate hemostasis is achieved, typically within 12-24 hours postoperatively 4, 6
• For patients who required discontinuation of P2Y12 inhibitors, consider loading doses when resuming therapy 1, 6
• The risk of cardiovascular events increases significantly with prolonged discontinuation of antiplatelet therapy 6