Antiplatelet Discontinuation Before Surgical Debridement
For surgical debridement, stop clopidogrel 5 days before the procedure, prasugrel 7 days before, and aspirin 7-10 days before if the patient is at low cardiovascular risk—but continue aspirin in moderate-to-high cardiovascular risk patients. 1
Risk-Stratified Approach to Antiplatelet Management
The decision to stop antiplatelets depends critically on both the bleeding risk of the procedure and the patient's thrombotic risk:
For Aspirin (ASA):
- Moderate-to-high cardiovascular risk patients: Continue aspirin throughout the perioperative period rather than stopping it 1
- Low cardiovascular risk patients: Stop aspirin 7-10 days before surgery 1
- Minor procedures (dental, dermatologic, cataract): Continue aspirin regardless of risk 1
For P2Y12 Inhibitors (Clopidogrel, Prasugrel, Ticagrelor):
- Clopidogrel: Discontinue 5 days before surgery 1
- Prasugrel: Discontinue 7 days before surgery 1, 2
- Ticagrelor: Discontinue 5 days before surgery 1
The rationale is that platelet function recovers at approximately 10-14% per day after stopping these irreversible platelet inhibitors, requiring 5-7 days for adequate hemostatic function 1, 3
Special Considerations for High-Risk Patients
Patients with Coronary Stents:
This is where the algorithm becomes critical and potentially life-saving:
- Bare-metal stents: Defer elective surgery for at least 6 weeks after placement 1
- Drug-eluting stents: Defer elective surgery for at least 6 months after placement 1
- If surgery cannot be delayed: Continue dual antiplatelet therapy perioperatively rather than stopping 7-10 days before surgery 1
The risk of stent thrombosis with premature antiplatelet discontinuation far exceeds the bleeding risk in most surgical scenarios 4, 5
Patients Requiring CABG:
- Continue aspirin throughout the perioperative period 1
- Stop clopidogrel 5 days before surgery 1
- Stop prasugrel 7 days before surgery 1, 2
Resumption of Antiplatelet Therapy
Resume antiplatelet therapy within 12-24 hours after surgery when adequate hemostasis is achieved, rather than delaying resumption 1, 6
- For clopidogrel at maintenance dose (75 mg/day), maximal platelet inhibition takes 5-10 days 1, 6
- A loading dose (300-600 mg) achieves maximal inhibition within 12-15 hours if rapid effect is needed 1, 6
Critical Pitfalls to Avoid
Never use bridging anticoagulation (heparin or LMWH) as a substitute for antiplatelet therapy in patients with coronary stents—this does not protect against stent thrombosis 7, 5
Do not transfuse platelets prophylactically before surgery in patients on antiplatelets; reserve platelet transfusion only for active bleeding thought to be related to antiplatelet effects 8
Platelet transfusions are less effective if given within 6 hours of prasugrel loading dose or 4 hours of maintenance dose, or within 4 hours of clopidogrel loading dose or 2 hours of maintenance dose 2, 3
Surgical Debridement-Specific Context
For surgical debridement specifically, the bleeding risk is typically moderate. Unless the debridement involves a closed space (intracranial, spinal canal, posterior eye chamber) or the patient has a recent coronary stent, the standard discontinuation intervals apply 1, 7
In patients with recent acute coronary events or stents, the thrombotic risk of stopping antiplatelets exceeds the bleeding risk of continuing them for most debridement procedures 4, 7, 5