When should antiplatelet medications, such as aspirin, clopidogrel (Plavix), or ticagrelor (Brilinta), be stopped prior to surgery?

When to Stop Antiplatelets Prior to Surgery

For most non-cardiac surgeries, aspirin should be continued perioperatively, while P2Y12 inhibitors should be stopped 3-5 days for ticagrelor, 5 days for clopidogrel, and 7 days for prasugrel before elective procedures. 1

Aspirin Management

Aspirin continuation is generally recommended for most surgical procedures unless bleeding would occur in a closed space (intracranial, spinal canal, posterior eye chamber) or the surgery carries exceptionally high bleeding risk. 1

• When aspirin interruption is necessary, stop ≤7 days before surgery rather than the traditional 7-10 days 1
• For high-bleed-risk procedures (intracranial, spinal surgery), interruption up to 7 days may be considered 1
• The POISE-2 trial showed aspirin continuation increased major bleeding (4.6% vs 3.8%) without reducing cardiovascular events, but this must be weighed against individual thrombotic risk 1

P2Y12 Inhibitor Management

Clopidogrel (Plavix)

• Stop 5 days before elective non-cardiac surgery 1, 2
• For urgent CABG, discontinue at least 24 hours before surgery to reduce major bleeding 1
• Approximately 10-14% of normal platelet function returns per day after stopping 2

Ticagrelor (Brilinta)

• Stop 3-5 days before elective non-cardiac surgery 1, 3
• This represents a significant change from older recommendations of 7-10 days, based on emerging evidence showing adequate platelet recovery with shorter interruption 1, 3
• For elective CABG, stop at least 5 days before surgery 1, 3
• For urgent CABG, discontinue at least 24 hours before surgery 1, 3

Prasugrel

• Stop 7 days before elective surgery due to its more prolonged and potent antiplatelet effect 1

Critical Timing Considerations Based on Stent Status

Elective surgery requiring P2Y12 inhibitor discontinuation should be delayed based on stent type and timing:

• After bare metal stent: Delay elective surgery for at least 4-6 weeks, ideally 6 weeks 1, 3
• After drug-eluting stent: Delay elective surgery for at least 6 months 1, 3
• Within 1 month of any stent or acute coronary syndrome: Do NOT discontinue dual antiplatelet therapy for elective surgery 1

High-Risk Window Management

For patients requiring surgery 1-6 months after stent placement where aspirin can be maintained throughout, surgery may be considered after 1 month with P2Y12 inhibitor discontinuation 1

CABG-Specific Recommendations

For coronary artery bypass grafting, different rules apply:

• Aspirin: Continue perioperatively or stop only 4 days before surgery; resume within 24 hours post-operatively 1
• Clopidogrel/Ticagrelor: Stop at least 5 days before elective CABG 1
• Prasugrel: Stop at least 7 days before elective CABG 1
• For urgent CABG: May proceed 24 hours after stopping P2Y12 inhibitors, though bleeding risk increases 1

Resumption of Antiplatelet Therapy

Resume antiplatelet therapy within 24 hours after surgery once hemostasis is achieved, given the substantial thrombotic risk associated with lack of platelet inhibition early post-operatively. 1, 3

• For clopidogrel or prasugrel, consider a loading dose (300-600 mg clopidogrel) if rapid antiplatelet effect is needed 2
• Resumption timing should be determined via multidisciplinary discussion before surgery and documented 1

Surgery-Specific Bleeding Risk Stratification

Low-to-Moderate Bleeding Risk Procedures

Continue dual antiplatelet therapy throughout the perioperative period 1

High-to-Very-High Bleeding Risk Procedures

• Stop P2Y12 inhibitor per timing above
• Continue aspirin if possible 1
• Examples: CABG, intracranial surgery, spinal canal surgery, posterior chamber eye surgery 1

Important Caveats and Pitfalls

Common pitfalls to avoid:

• Do not routinely use platelet function testing to guide perioperative management—it is not recommended and does not improve outcomes 1
• Do not substitute heparin or LMWH for antiplatelet therapy—this provides no protection against coronary or stent thrombosis 1, 4
• Do not transfuse platelets prophylactically—reserve for active bleeding thought related to antiplatelet effects 1, 5
• Beware of drug interactions: Avoid omeprazole/esomeprazole with clopidogrel as they significantly reduce its antiplatelet activity 6

The thrombotic risk of withdrawing antiplatelet therapy generally exceeds the bleeding risk of continuing it, except in closed-space surgeries or procedures with exceptionally high bleeding risk. 4, 7