How Long to Hold Plavix (Clopidogrel) Prior to Non-Cardiac Surgery
For elective non-cardiac surgery, stop clopidogrel 5 days before the procedure. 1, 2, 3
Standard Timing for Elective Surgery
Clopidogrel should be discontinued 5 days before elective non-cardiac surgery to allow adequate platelet function recovery while minimizing bleeding risk. 1, 2
The FDA label for clopidogrel explicitly states: "When possible, interrupt therapy with clopidogrel for five days prior to such surgery." 3
This 5-day window is based on the irreversible platelet inhibition caused by clopidogrel, which affects platelets for their entire 7-10 day lifespan, with approximately 10-14% of normal platelet function restored for each day after discontinuation. 2, 3
High Bleeding Risk Procedures
For surgeries with very high bleeding risk (intracranial surgery, spinal canal procedures, posterior chamber eye surgery), the 5-day discontinuation period remains appropriate, though some guidelines suggest up to 7 days may be considered. 1
The distinction here is critical: these closed-space procedures have catastrophic consequences from bleeding, justifying the longer interruption period. 1, 4
Urgent/Emergency Surgery Considerations
For urgent non-cardiac surgery, clopidogrel should be stopped for at least 24 hours to reduce major bleeding complications when delaying surgery is not feasible. 1
This represents a balance between thrombotic and bleeding risks when the clinical situation does not permit the standard 5-day waiting period. 1
Critical Exception: Recent Coronary Stents
This is where most complications occur in practice. If the patient has a coronary stent placed within the last 6-12 weeks, you face a different risk calculation:
For bare-metal stents: delay elective surgery for at least 30-45 days after stent placement, during which dual antiplatelet therapy (aspirin + clopidogrel) should be continued. 1, 2
For drug-eluting stents: delay elective surgery for at least 6-12 months after stent placement to allow complete endothelialization. 1, 2
If surgery cannot be delayed in stent patients, consider continuing aspirin alone while stopping clopidogrel, or continuing both agents if bleeding risk permits. 1, 2
Shorter Discontinuation Periods: The Evidence Gap
The 2022 American College of Chest Physicians guidelines suggest a more nuanced approach:
Ticagrelor can be stopped 3-5 days before surgery (rather than the traditional 7-10 days), reflecting its more rapid offset of action. 1
While no high-quality prospective data exist for clopidogrel discontinuation timing in non-cardiac surgery, retrospective studies suggest increased bleeding with continuation. 1
One cardiac surgery study found no significant difference in bleeding between stopping clopidogrel 3 days versus 5 days before CABG, but this cannot be extrapolated to non-cardiac surgery without caution. 5
Resumption After Surgery
Restart clopidogrel within 24 hours after surgery once hemostasis is achieved, rather than delaying longer. 1, 2, 3
The FDA label states: "Resume clopidogrel as soon as hemostasis is achieved." 3
If rapid antiplatelet effect is needed postoperatively, a loading dose (300-600 mg) achieves maximal inhibition within 12-15 hours, versus 5-10 days with the standard 75 mg maintenance dose. 2
Common Pitfalls to Avoid
Do not routinely use platelet function testing to guide timing of surgery—this is not recommended by current guidelines and adds no proven benefit. 2
Do not substitute heparin or low-molecular-weight heparin for clopidogrel during the perioperative period, as these do not protect against coronary stent thrombosis. 4
Do not stop clopidogrel earlier than 5 days for elective surgery based on older recommendations of 7-10 days—the current evidence supports 5 days as adequate and potentially safer by reducing thrombotic risk. 1, 2
Aspirin management differs from clopidogrel: For most non-cardiac surgeries, aspirin can be continued perioperatively (except in closed-space procedures), whereas clopidogrel requires discontinuation. 1