Perioperative Medication Management
Direct Answer
For most procedures, continue ASA and hold Plavix 5 days before; continue metoprolol, procardia, and bumex on the day of procedure. The specific management depends critically on the procedure type, bleeding risk, and your cardiovascular risk profile—particularly whether you have coronary stents.
Antiplatelet Medications (ASA and Plavix)
ASA (Aspirin) Management
Continue ASA through the procedure day for most situations 1. The 2022 American College of Chest Physicians guidelines recommend:
- For minor procedures (dental, dermatologic, cataract surgery): Continue ASA regardless of cardiovascular risk 1, 2
- For moderate-to-high cardiovascular risk patients (prior MI, stroke, coronary stents): Continue ASA perioperatively 1, 2
- For low cardiovascular risk patients undergoing high-bleeding-risk surgery: Stop ASA ≤7 days (not the outdated 7-10 days) before surgery 1, 2
The evidence shows that continuing ASA increases minor bleeding but does not increase major bleeding requiring intervention, while discontinuation significantly increases cardiovascular events 1.
Plavix (Clopidogrel) Management
Stop Plavix 5 days before most procedures 1, 2, 3. However, critical exceptions exist:
- If you have coronary stents placed within 6 weeks (bare-metal) or 6 months (drug-eluting): Continue both ASA and Plavix through the procedure if surgery cannot be deferred 1, 2
- After 6 months post-stent: Continue ASA but stop Plavix 5 days before surgery 2, 3
- For minor procedures (dental, dermatologic, cataract): Can continue Plavix 1, 4
Resume Plavix within 24 hours after surgery when adequate hemostasis is achieved 1, 2. Consider a 300 mg loading dose when resuming in patients with drug-eluting stents 2, 3.
Cardiovascular Medications (Metoprolol and Procardia)
Continue metoprolol (beta-blocker) and procardia (nifedipine/calcium channel blocker) on the day of procedure. These medications should not be held perioperatively as they:
- Prevent rebound hypertension and tachycardia
- Reduce perioperative cardiac events
- Have no significant impact on surgical bleeding risk
Take these medications with a small sip of water on the morning of surgery, even if NPO.
Diuretic (Bumex)
The decision to hold or continue bumex (bumetanide) depends on your volume status and the procedure:
- Generally hold on the morning of surgery to avoid intraoperative hypotension and electrolyte disturbances
- Continue if you have significant volume overload (active heart failure)
- Discuss with your anesthesiologist, as this is procedure-specific
Critical Decision Algorithm
Step 1: Identify Your Cardiovascular Risk
- High risk: Recent coronary stent (<6-12 months), recent MI/stroke, multiple cardiovascular risk factors 1
- Low risk: ASA for primary prevention only, no significant cardiovascular disease 1
Step 2: Classify Procedure Bleeding Risk
- Low bleeding risk: Dental, dermatologic, cataract, most endoscopic procedures 1
- High bleeding risk: Intracranial, spinal canal, posterior eye chamber surgery 1, 5
Step 3: Apply Management Strategy
- Low bleeding risk procedure: Continue all antiplatelets regardless of cardiovascular risk 1
- High bleeding risk + high cardiovascular risk: Continue ASA, hold Plavix 5 days before 1
- High bleeding risk + low cardiovascular risk: Hold ASA ≤7 days and Plavix 5 days before 1
- Recent coronary stent (<6-12 months): Continue both ASA and Plavix if surgery cannot be deferred 1
Common Pitfalls to Avoid
- Do not use the outdated 7-10 day window for ASA cessation—the updated guideline recommends ≤7 days, which reduces unnecessary thrombotic risk 1, 2
- Do not forget to report over-the-counter NSAIDs (ibuprofen, naproxen) which have antiplatelet effects and increase bleeding risk 2, 3
- Do not hold ASA in patients with coronary stents—the thrombotic risk far exceeds bleeding risk 1, 5
- Do not bridge antiplatelet therapy with heparin—this provides no protection against coronary or stent thrombosis 5