How long should a patient stop taking aspirin and clopidogrel before elective surgery?

Preoperative Discontinuation of Aspirin (Ecospirin) and Clopidogrel

For elective surgery, discontinue clopidogrel at least 5 days before the procedure, while aspirin should be stopped 3-5 days preoperatively for high-bleeding-risk surgeries but can be continued for most other procedures. 1, 2, 3

Clopidogrel Discontinuation Timeline

Stop clopidogrel 5 days (120 hours) before elective surgery to allow adequate platelet function recovery. 1, 3, 4

• This 5-day window applies to most elective procedures and is supported by the highest-level guideline recommendations from the American College of Cardiology/American Heart Association. 1
• The FDA drug label for clopidogrel specifically instructs physicians to discuss stopping the medication at least 5 days before surgery to avoid excessive bleeding. 4
• For prasugrel specifically, extend the discontinuation period to at least 7 days before surgery. 1

Urgent Surgery Exception

• If surgery cannot be delayed, clopidogrel may be stopped just 24 hours before urgent procedures, accepting the increased bleeding risk when thrombotic risk outweighs surgical delay. 1
• Recent evidence from 2016 shows that discontinuing ticagrelor 3 days (72 hours) before CABG does not increase major bleeding compared to 5+ days, though this shorter window increased bleeding risk with clopidogrel. 5

Aspirin (Ecospirin) Discontinuation Timeline

Stop aspirin 5 days before high-bleeding-risk surgeries; for most other procedures, aspirin can be continued throughout the perioperative period. 2, 3

High-Bleeding-Risk Surgeries Requiring Aspirin Cessation (5 days preoperatively):

• Neurosurgery and intracranial procedures 2, 6
• Spinal surgery within the medullary canal 6
• Posterior chamber eye surgery 6
• Any surgery in a closed anatomical space 3, 6
• Procedures with expected excessive blood loss 3, 6

Surgeries Where Aspirin Should Be Continued:

• Coronary artery bypass grafting (CABG): Non-enteric-coated aspirin (81-325 mg daily) should be administered preoperatively and continued. 1
• Most vascular procedures including carotid endarterectomy and peripheral bypass 1, 3
• Most major surgeries where bleeding can be controlled 3, 6

Special Cardiac Surgery Considerations

For patients undergoing CABG, continue aspirin but stop clopidogrel/ticagrelor 5 days before and prasugrel 7 days before elective procedures. 1

• Aspirin improves saphenous vein graft patency and should be the standard of care perioperatively for CABG, despite increasing blood loss and reoperation rates. 1
• The CURE trial demonstrated that stopping clopidogrel fewer than 5 days before CABG significantly increased major bleeding (9.6% vs 6.3%) without affecting mortality. 1

Patients with Coronary Stents: Critical Timing

Delay elective surgery for at least 6 weeks after bare metal stent placement and 6 months (preferably 12 months) after drug-eluting stent placement. 3, 6

• If surgery cannot be delayed in stented patients, continue aspirin and only stop the P2Y12 inhibitor (clopidogrel) 5 days before, as the thrombotic risk of stopping both agents is catastrophic. 3, 6
• The risk of stent thrombosis from withdrawing antiplatelet therapy exceeds the risk of surgical bleeding in most cases. 6

Resuming Therapy Postoperatively

Resume both aspirin and clopidogrel within 12-24 hours after surgery once adequate hemostasis is achieved. 2, 6

• Consider a loading dose of at least 300 mg clopidogrel when resuming therapy to rapidly restore antiplatelet effect. 3

Critical Pitfalls to Avoid

• Never use heparin or low-molecular-weight heparin as "bridging therapy" to replace antiplatelet agents perioperatively—this does not protect against coronary or stent thrombosis and may increase bleeding risk. 6
• Do not transfuse platelets prophylactically; reserve platelet transfusion only for patients with active abnormal bleeding thought related to antiplatelet effects. 1, 7
• While aspirin irreversibly affects platelets for 7-10 days, only 20% of circulating platelets need normal function for adequate hemostasis, which is why 3-5 days discontinuation suffices for most surgeries. 2, 8
• Consult cardiology before stopping antiplatelet therapy in high thrombotic risk patients (recent acute coronary syndrome, recent stent placement). 2, 3