How many days prior to surgery should clopidogrel (Plavix) be held in a patient with coronary artery disease (CAD) and recent stent placement?

Clopidogrel Discontinuation Prior to Surgery

For elective non-cardiac surgery, discontinue clopidogrel 5 days before the procedure, unless the patient has a recent coronary stent (bare-metal stent within 6 weeks or drug-eluting stent within 12 months), in which case surgery must be postponed or performed on clopidogrel after mandatory cardiology consultation. 1

Standard Timing by Procedure Risk

Elective Surgery Protocol:

• 5 days discontinuation is the standard for most elective surgeries including intermediate-risk procedures like cystoscopy, retrograde intrarenal surgery, and percutaneous nephrolithotomy 1, 2
• 5-7 days discontinuation is required for high-bleeding-risk procedures in closed spaces (CABG, neurosurgery, retinal surgery, spinal procedures), with 7 days being preferable for optimal platelet recovery 3
• The FDA label confirms that clopidogrel should be interrupted for 5 days prior to surgery with major bleeding risk, as it irreversibly inhibits platelets for their 7-10 day lifetime 4

Urgent Surgery Protocol:

• Minimum 24 hours discontinuation reduces major bleeding risk when waiting 5 days is not feasible, though this carries increased bleeding risk compared to the full washout period 3
• For CABG specifically, a meta-analysis demonstrated that patients undergoing surgery <5 days after clopidogrel had significantly greater incidence of reoperation, major bleeding, and combined adverse outcomes compared to >5 days washout 5

Critical Stent Considerations

Never discontinue clopidogrel without cardiology consultation in patients with: 1

• Drug-eluting stents placed within 12 months (highest risk period)
• Bare-metal stents placed within 6 weeks (critical period)
• Recent acute coronary syndrome
• Recent stroke or TIA

The American Heart Association emphasizes that abrupt clopidogrel cessation dramatically increases the risk of stent thrombosis, myocardial infarction, and death—this is the leading cause of stent thrombosis with potentially fatal consequences. 1 The highest thrombotic risk occurs within 30 days of stent placement, with ongoing risk of 0.2-0.6% per year thereafter 1

Aspirin Management During Clopidogrel Interruption

Continue aspirin 75-100mg daily throughout the perioperative period when clopidogrel must be stopped, as aspirin alone does not significantly increase bleeding risk in most procedures and provides critical cardiovascular protection 1, 3

Procedure-Specific Timing

High-risk bleeding procedures (CABG, neurosurgery, spinal procedures):

• Require full 5-7 day discontinuation without exception 3
• Research shows that even 7 days may not fully eliminate increased bleeding risk compared to non-clopidogrel patients 6

Intermediate-risk procedures (endoscopy with polypectomy, urological procedures):

• 5-day discontinuation window applies 1
• Class I, Level B evidence supports no increase in bleeding or transfusions when surgery performed ≥5 days after stopping clopidogrel 1

Peripheral arterial surgery:

• One prospective study of 647 procedures found no significant difference in bleeding complications when continuing clopidogrel through surgery 7, though this contradicts guideline recommendations and should not override the standard 5-day protocol for most surgical contexts

Postoperative Resumption

Restart clopidogrel as soon as adequate hemostasis is achieved postoperatively, typically within 24 hours if no active bleeding 1, 4

Evidence Quality Note

The 5-day discontinuation protocol is based on Class I, Level C evidence (expert consensus) but remains the standard of care endorsed by the American College of Cardiology and American Heart Association 3. The FDA label directly supports this timing 4.