Protocol for Holding Clopidogrel Prior to Surgery
For elective surgery, discontinue clopidogrel at least 5 days before the procedure, and resume as soon as hemostasis is achieved postoperatively. 1, 2
Standard Elective Surgery Protocol
Timing of Discontinuation
Discontinue clopidogrel 5 days before elective surgery to allow adequate platelet function recovery, as clopidogrel irreversibly inhibits platelet aggregation for the lifetime of the platelet (7-10 days). 1, 2
For CABG specifically, the American Heart Association guidelines recommend discontinuation for 5-7 days before elective surgery, with 7 days being preferable for optimal platelet recovery. 1
Prasugrel requires 7 days of discontinuation before surgery due to its more potent and prolonged antiplatelet effects. 1
Ticagrelor requires only 5 days of discontinuation before surgery. 1
Resumption After Surgery
- Resume clopidogrel as soon as hemostasis is achieved postoperatively, typically within 24-48 hours, as discontinuation increases cardiovascular event risk. 2
Urgent/Emergency Surgery Protocol
For urgent surgery where waiting 5 days is not feasible, discontinue clopidogrel for at least 24 hours to reduce major bleeding risk, though this carries increased bleeding risk compared to the full 5-day washout. 1
This 24-hour minimum applies specifically to urgent CABG situations where delaying surgery poses greater risk than the bleeding risk from recent clopidogrel exposure. 1
Experienced surgeons may proceed with "early" CABG (within 5 days of clopidogrel) at acceptable incremental bleeding risk in urgent situations, though blood transfusion requirements increase. 1
Risk Stratification for Decision-Making
High Thrombotic Risk Patients (Defer Surgery if Possible)
Patients at high risk for thrombotic events should have elective procedures deferred until clopidogrel can be safely discontinued for the full 5-7 days. 1
High-risk features include:
- Drug-eluting stents placed within 12 months 1
- Bare-metal stents placed within 1 month 3
- Recent acute coronary syndrome (within weeks to months) 1
- Recent stroke or TIA 1
For these patients, cardiology consultation is mandatory before any clopidogrel interruption to assess thrombotic versus bleeding risk. 4
Aspirin Management
Continue aspirin throughout the perioperative period unless the bleeding risk is prohibitive, as aspirin alone poses minimal bleeding risk and provides critical cardiovascular protection. 1, 4
- For patients on dual antiplatelet therapy (clopidogrel + aspirin), stopping clopidogrel while continuing aspirin reduces bleeding risk while maintaining some cardiovascular protection. 1
Procedure-Specific Considerations
High Bleeding Risk Procedures
For procedures with high bleeding risk in closed spaces (neurosurgery, retinal surgery, spinal procedures):
- Require the full 5-7 day discontinuation period without exception. 3, 5
- These procedures have catastrophic consequences from even minor bleeding. 5
Moderate Bleeding Risk Procedures
For endoscopic procedures with high bleeding risk (polypectomy, sphincterotomy, endoscopic submucosal dissection):
- Discontinue clopidogrel for 7 days before the procedure. 1
- Continue aspirin if cardiovascular risk is high. 1
Lower Bleeding Risk Procedures
Recent research suggests that for peripheral arterial surgery and some major vascular procedures, continuing clopidogrel may be safe and does not significantly increase bleeding complications. 6, 7
However, guideline recommendations still favor the 5-day discontinuation protocol for consistency and to minimize medicolegal risk. 1, 2
Common Pitfalls to Avoid
Do not stop clopidogrel for less than 5 days in elective surgery unless the thrombotic risk clearly outweighs bleeding risk, as 3-4 days provides inadequate platelet recovery. 8
Do not delay resumption of clopidogrel postoperatively beyond achieving hemostasis, as each day without antiplatelet therapy increases thrombotic event risk. 2
Do not discontinue both aspirin and clopidogrel simultaneously in high-risk cardiac patients unless absolutely necessary for the procedure. 1
Do not proceed with elective surgery in patients with recent drug-eluting stents (within 12 months) without cardiology consultation, as stent thrombosis carries 20-45% mortality. 1
Evidence Quality Note
While the 5-day discontinuation protocol is based on Class I, Level C evidence (expert consensus rather than randomized trials), it remains the standard of care endorsed by the American College of Cardiology and American Heart Association. 1, 2 Some recent observational studies suggest shorter discontinuation periods (3 days) may be adequate, but these have not been validated in prospective trials and should not change current practice. 9, 8