Perioperative Management of Aspirin and Clopidogrel in Surgical Patients
Continue aspirin throughout the perioperative period for all patients unless the surgery involves bleeding in closed spaces (intracranial, spinal canal, or posterior chamber eye surgery), and discontinue clopidogrel 5 days before surgery (7 days for prasugrel, 3-5 days for ticagrelor), resuming it as soon as hemostasis is achieved postoperatively. 1, 2
Aspirin Management
Aspirin should be maintained perioperatively in nearly all surgical contexts because the thrombotic risk of discontinuation (myocardial infarction, stroke, stent thrombosis) typically exceeds the bleeding risk. 1, 3
Continue aspirin for: Patients with coronary stents, prior myocardial infarction, peripheral vascular disease, cerebrovascular disease, or any cardiovascular risk factors undergoing most surgical procedures including carotid endarterectomy, lower extremity bypass, abdominal aortic surgery, and general surgical procedures. 1, 2, 3
Discontinue aspirin 7-10 days preoperatively only for: Intracranial neurosurgery, spinal canal surgery, or posterior chamber eye surgery where bleeding occurs in closed spaces with potentially catastrophic consequences. 3, 4
Minor procedures: Continue aspirin without interruption for dental, dermatologic, cataract surgery, and endoscopic procedures. 3
Clopidogrel Management
Clopidogrel must be stopped because it irreversibly inhibits platelet aggregation for the platelet's 7-10 day lifespan, creating significantly increased bleeding risk if continued. 5
Standard discontinuation timing: Stop clopidogrel 5 days before surgery to allow adequate platelet function recovery. 1, 2
Prasugrel requires 7 days of discontinuation due to more potent and prolonged platelet inhibition. 1
Ticagrelor requires only 3-5 days due to reversible binding and shorter duration of action. 1, 6
Resume clopidogrel within 12-24 hours postoperatively as soon as hemostasis is achieved; some experts recommend a 300 mg loading dose. 1, 4
Critical Exception: Patients with Coronary Stents
The presence and timing of coronary stent placement fundamentally changes management because stent thrombosis carries 20-45% mortality risk, far exceeding surgical bleeding risk in most contexts. 1, 7
Drug-Eluting Stents (DES)
If stent placed <6 months ago: Postpone all elective surgery until 6 months post-stent if at all possible. 1, 7
If surgery cannot be delayed: Maintain aspirin throughout and stop clopidogrel only 5 days preoperatively, resuming immediately postoperatively. 1, 2, 7
If surgery is truly emergent/urgent: Consider maintaining both aspirin AND clopidogrel through surgery except for intracranial or closed-space procedures. 1, 7, 6
Bare-Metal Stents (BMS)
If stent placed <4-6 weeks ago: Postpone all elective surgery until at least 6 weeks post-stent. 1, 7
If surgery cannot be delayed: Maintain both aspirin and clopidogrel if at all possible, as stent thrombosis risk is maximal during this period. 7, 6
High-Risk Stent Features Requiring Extra Caution
Patients with the following features have extremely high stent thrombosis risk and require multidisciplinary discussion (cardiologist, surgeon, anesthesiologist, hematologist) before any antiplatelet modification: 1, 7
- History of prior stent thrombosis
- Multiple stents, long stents, or bifurcation stents
- Incomplete revascularization
- Diabetes mellitus
- Left ventricular ejection fraction <40%
Surgery-Specific Bleeding Risk Categories
Minor Bleeding Risk Procedures
Continue both aspirin and clopidogrel for dental extractions, dermatologic procedures, cataract surgery, and diagnostic endoscopy. 3
Intermediate Bleeding Risk Procedures
Continue aspirin, stop clopidogrel 5 days preoperatively for most general surgical procedures, orthopedic surgery, and major endoscopic procedures. 1, 3
Major Bleeding Risk Procedures
Continue aspirin if patient has stents, stop clopidogrel 5 days preoperatively for cardiac surgery, major vascular surgery, cancer surgery, and urologic procedures. 1, 3
Stop both aspirin and clopidogrel only for intracranial neurosurgery, spinal canal surgery, and posterior chamber eye surgery. 3, 4
Critical Pitfalls to Avoid
Never discontinue both aspirin and clopidogrel simultaneously in patients with stents placed within the past 6-12 months (DES) or 4-6 weeks (BMS), as this dramatically increases stent thrombosis risk with mortality rates of 20-45%. 1, 2, 7, 3
Never substitute antiplatelet therapy with heparin or low-molecular-weight heparin bridging, as anticoagulants do not prevent stent thrombosis and actually increase bleeding risk without providing adequate platelet inhibition. 2, 3, 4
Never use vitamin K for routine warfarin reversal before elective surgery; instead stop warfarin 5 days preoperatively and allow natural INR decline. 3
Do not rely on platelet transfusions to reverse clopidogrel effect within 4 hours of loading dose or 2 hours of maintenance dose, as they are largely ineffective during this timeframe. 5
Postoperative Resumption
Resume clopidogrel within 12-24 hours after surgery as soon as adequate hemostasis is achieved. 1, 4
Consider a 300 mg loading dose of clopidogrel when resuming therapy postoperatively to rapidly restore platelet inhibition. 1
Continue aspirin throughout the postoperative period without interruption. 1, 2
Emergency Surgery Management
For truly emergent surgery that cannot be delayed (e.g., ruptured abdominal aortic aneurysm, acute surgical abdomen), proceed with surgery while maintaining antiplatelet therapy and prepare for increased bleeding: 1, 6
- Have platelet transfusions immediately available (though effectiveness is limited if clopidogrel taken within 2-4 hours)
- Consider antifibrinolytic agents (tranexamic acid or aminocaproic acid) to promote hemostasis
- Avoid aprotinin due to increased risk of renal failure, myocardial infarction, and stroke 1
- Use meticulous surgical technique with aggressive local hemostatic measures