When should clopidogrel (Plavix) be held prior to surgery?

When to Hold Clopidogrel for Surgery

For elective non-cardiac surgery, stop clopidogrel 5 days before the procedure to allow adequate platelet function recovery while minimizing bleeding complications. 1, 2, 3

Elective Non-Cardiac Surgery

• Discontinue clopidogrel 5 days preoperatively as the standard approach for most elective non-cardiac procedures 1, 2
• The 5-day interval is based on the irreversible platelet inhibition caused by clopidogrel, which affects platelets for their entire 7-10 day lifespan 3
• Stopping clopidogrel less than 5 days before surgery significantly increases major bleeding (9.6% vs 6.3%) and reoperation rates (3.2% vs 1.8%) 1, 2
• The FDA label explicitly states: "When possible, interrupt therapy with clopidogrel for five days prior to such surgery" 3

Elective CABG Surgery

• Stop clopidogrel at least 5 days before elective CABG to reduce major bleeding and transfusion requirements 1, 2
• Meta-analysis data demonstrate that >5 days cessation results in lower reoperation rates (1.8% vs 3.2%) and reduced major bleeding (19.7% vs 30.2%) compared to <5 days 1, 2
• Continue aspirin perioperatively for CABG, but interrupt P2Y12 inhibitors like clopidogrel 1

Urgent CABG Surgery

• Discontinue clopidogrel for at least 24 hours before urgent CABG when surgery cannot be delayed 1, 2
• While 24-hour cessation reduces major bleeding compared to continuing therapy, bleeding risk remains elevated compared to the full 5-day interval 1, 2
• It may be reasonable to perform urgent CABG less than 5 days after clopidogrel discontinuation when clinical circumstances demand it 1

High-Risk Patients with Recent Coronary Stents

This is the critical exception where delaying surgery takes priority over the standard 5-day rule:

• Delay elective surgery for at least 4-6 weeks after bare metal stent placement and at least 6 months after drug-eluting stent placement 2
• For patients with stents placed within 6-12 weeks requiring elective surgery, either continue both antiplatelet agents or stop one agent within 7-10 days, balancing bleeding versus thrombotic risk 1, 2
• The risk of stent thrombosis from premature clopidogrel discontinuation can be catastrophic and often outweighs surgical bleeding risk 1
• Mandatory cardiology consultation is required before discontinuing clopidogrel in patients with recent stents 2

Post-Surgical Resumption

• Resume clopidogrel within 24 hours after surgery as soon as hemostasis is achieved 1, 2, 3
• Delay resumption only if post-operative thrombocytopenia develops (platelet count <50,000/μL), which typically occurs with on-pump cardiac surgery 1, 2

Common Pitfalls to Avoid

• Do not routinely use platelet function testing to guide perioperative clopidogrel management, as guidelines recommend against this practice 1
• Do not substitute heparin or low-molecular-weight heparin for clopidogrel during the perioperative period, as these agents do not protect against coronary artery or stent thrombosis 4
• Do not transfuse platelets prophylactically; reserve platelet transfusion only for patients with active abnormal bleeding thought to be related to antiplatelet effects 5
• Platelet transfusions are less effective if given within 4 hours of a clopidogrel loading dose or 2 hours of a maintenance dose 3

Special Surgical Considerations

For surgeries where bleeding occurs in closed spaces (intracranial surgery, spinal canal surgery, posterior chamber eye surgery), the 5-day cessation rule becomes even more critical due to the catastrophic consequences of bleeding in these locations 4.