How long should Plavix (clopidogrel) be held before total hip replacement surgery in a patient with a history of cardiovascular disease?

Plavix Discontinuation Before Total Hip Replacement

For elective total hip replacement, discontinue Plavix (clopidogrel) 5 days before surgery. 1, 2, 3

Primary Recommendation

The ACC/AHA guidelines consistently recommend stopping clopidogrel at least 5 days before elective surgery to allow adequate platelet function recovery while minimizing bleeding risk. 1, 2 The FDA label for clopidogrel specifically states: "When possible, interrupt therapy with clopidogrel for five days prior to such surgery." 3

Physiologic Rationale

• Clopidogrel irreversibly inhibits platelets for their entire 7-10 day lifespan. 3, 4
• Approximately 10-14% of normal platelet function returns for each day after discontinuation. 2
• After 5 days, sufficient new platelets have been generated to restore adequate hemostasis for most surgical procedures. 1, 2

Special Considerations for Patients with Coronary Stents

Drug-Eluting Stents (DES)

• Ideally postpone elective total hip replacement for at least 6 months after DES placement. 2
• If surgery cannot be delayed, consider continuing aspirin monotherapy and stopping only clopidogrel. 2

Bare Metal Stents (BMS)

• Wait at least 6 weeks after BMS placement before elective total hip replacement. 2, 5

High Thrombotic Risk Patients

• Consultation with cardiology is essential before discontinuing clopidogrel in patients with recent acute coronary syndrome or stent placement. 6

Urgent Surgery Considerations

For urgent hip fracture surgery, the evidence supports operating within 24-48 hours despite clopidogrel use rather than delaying surgery. 1, 7, 8

• ACC/AHA guidelines state that for urgent surgery, clopidogrel should be discontinued for at least 24 hours to reduce major bleeding. 1
• Multiple studies demonstrate that early surgery (<48 hours) in hip fracture patients on clopidogrel does not increase mortality or perioperative bleeding compared to controls. 7, 8
• Surgical delay beyond 4 days in hip fracture patients increases postoperative mortality, making early intervention critical. 4

Perioperative Management Algorithm

For Elective Total Hip Replacement:

1. Stop clopidogrel 5 days before surgery 1, 2, 3
2. Continue aspirin if patient is on dual antiplatelet therapy (unless contraindicated by surgeon preference) 1
3. Resume clopidogrel within 24 hours after surgery once hemostasis is achieved 2, 3

For Urgent Hip Fracture Surgery:

1. Stop clopidogrel immediately upon admission 1
2. Proceed to surgery within 24-48 hours 1, 7, 8
3. Consider platelet transfusion if significant bleeding occurs (though transfusions within 2-4 hours of last dose may be less effective) 3, 9
4. Resume clopidogrel within 24 hours postoperatively 2

Common Pitfalls to Avoid

• Do not delay urgent hip fracture surgery for 5-7 days waiting for clopidogrel washout—this increases mortality without reducing bleeding risk. 7, 8
• Do not assume all antiplatelet agents have the same washout period—prasugrel requires 7 days, ticagrelor requires 3-5 days. 1, 2
• Do not restart clopidogrel at maintenance dose (75 mg) if rapid antiplatelet effect is needed—use loading dose of 300-600 mg to achieve effect within 12-15 hours. 2
• Do not perform elective surgery on patients within 6 months of DES placement without cardiology consultation. 2

Bleeding Risk Mitigation

• Accept that some increased bleeding may occur with early surgery in urgent cases, but this risk is outweighed by mortality reduction from timely intervention. 7, 8
• Ensure adequate blood products are available, though transfusion rates are similar between clopidogrel and non-clopidogrel patients in most studies. 8
• Platelet transfusions may provide some benefit if given more than 2-4 hours after the last clopidogrel dose. 3, 9