When should Aspirin (ASA) and Clopidogrel (Plavix) be stopped before surgery?

When to Stop Aspirin and Clopidogrel Before Surgery

For aspirin (ASA), stop ≤7 days before surgery in patients at low cardiovascular risk, but continue perioperatively in patients at moderate-to-high cardiovascular risk; for clopidogrel (Plavix), stop 5 days before surgery. 1, 2

Aspirin (ASA) Management

The timing of aspirin discontinuation depends critically on the patient's cardiovascular risk profile:

High/Moderate Cardiovascular Risk Patients

• Continue aspirin throughout the perioperative period for patients receiving ASA for secondary prevention of cardiovascular disease 1
• This includes patients with:
  • Prior myocardial infarction
  • Prior stroke
  • Established coronary artery disease
  • Coronary stents (especially drug-eluting stents) 1, 3
• Continue aspirin for CABG surgery 1

Low Cardiovascular Risk Patients

• Stop aspirin ≤7 days (not the traditional 7-10 days) before surgery 1, 3
• The updated 2022 American College of Chest Physicians guidelines shortened this window from the previous 7-10 day recommendation 1

Minor Procedures

• Continue aspirin for minor dental procedures, dermatologic procedures, and cataract surgery regardless of cardiovascular risk 1

Critical Exception - High Bleeding Risk Surgeries

• Stop aspirin 5-7 days preoperatively for neurosurgery and other closed-space surgeries where even minor bleeding can cause severe complications (intracranial surgery, spinal canal surgery, posterior chamber eye surgery) 3, 4

Clopidogrel (Plavix) Management

Stop clopidogrel 5 days before surgery in most circumstances 1, 2, 5

Key Considerations:

• Clopidogrel irreversibly inhibits platelet function for the lifetime of the platelet (7-10 days) 5
• The 5-day window allows sufficient time for new platelet generation 2
• For CABG surgery specifically, stopping clopidogrel 5 days preoperatively reduces major bleeding risk by approximately 50% and transfusion requirements by 70% 1

Patients with Coronary Stents - Critical Exception

This is the most important clinical scenario requiring deviation from standard recommendations:

• Defer elective surgery for at least 6 weeks after bare-metal stent placement and 6 months after drug-eluting stent placement 1
• If surgery cannot be deferred and must occur within these timeframes, continue dual antiplatelet therapy (both aspirin and clopidogrel) perioperatively despite bleeding risk 1
• The thrombotic risk of stent thrombosis substantially outweighs surgical bleeding risk in this population 6
• After 6 months post-drug-eluting stent: continue aspirin but stop clopidogrel 5 days before surgery 1

Resumption of Therapy

Resume both aspirin and clopidogrel within 24 hours after surgery when adequate hemostasis is achieved 1, 2, 3

• The FDA label for clopidogrel specifically states to "restart it as soon as possible" after temporary discontinuation 5
• Some experts recommend a 300 mg loading dose of clopidogrel when resuming therapy in patients with drug-eluting stents 2
• Earlier resumption (within 12 hours) may be appropriate for very high thrombotic risk patients 7

Common Pitfalls to Avoid

Discontinuing Too Early

• Many clinicians still use the outdated 7-10 day window for aspirin when ≤7 days is now recommended 1, 3
• This unnecessarily prolongs the period of increased thrombotic risk 3

Inadequate Medication Reconciliation

• Patients frequently fail to report over-the-counter NSAIDs with antiplatelet effects 2, 3
• Always perform thorough medication reconciliation including all OTC medications 3

Bridging with Heparin

• Do not attempt to "bridge" antiplatelet therapy with heparin or low-molecular-weight heparin 6
• Heparin does not provide protection against coronary artery or stent thrombosis in patients who require antiplatelet therapy 6

Multiple Antiplatelet/Anticoagulant Agents

• Bleeding risk increases significantly when multiple antiplatelet or anticoagulant medications are combined 2, 3
• Carefully assess the cumulative bleeding risk in these patients 3

Emergency Reversal

• If urgent surgery is needed in a patient on clopidogrel, platelet transfusions may restore hemostasis, but are less effective within 4 hours of the loading dose or 2 hours of the maintenance dose 5
• For aspirin, the effect is irreversible and only fresh platelets can restore normal hemostasis (at least 20% of circulating platelets must have normal function) 6