When to Hold Clopidogrel Before Elective D&C in Stroke Patients
For a stroke patient undergoing elective dilation and curettage (D&C), clopidogrel should be discontinued 5 days before the procedure unless the patient has a coronary stent, in which case cardiology consultation is mandatory before stopping the medication. 1, 2, 3
Critical Pre-Procedure Assessment
Before making any decision about clopidogrel discontinuation, you must determine:
Coronary stent status: If the patient has a drug-eluting stent placed within 12 months or a bare-metal stent within 6 weeks, do not stop clopidogrel without cardiology consultation, as abrupt cessation dramatically increases the risk of stent thrombosis, myocardial infarction, and death 1, 2, 3
Indication for clopidogrel: Distinguish between clopidogrel for secondary stroke prevention alone versus dual antiplatelet therapy following coronary intervention 2
Standard Timing for Clopidogrel Discontinuation
For patients WITHOUT recent coronary stents:
Stop clopidogrel 5 days before elective D&C to allow adequate platelet function recovery 1, 2, 3, 4
This 5-day window is based on the platelet lifespan and the irreversible nature of clopidogrel's antiplatelet effect 1, 4
The FDA label specifically states: "When possible, interrupt therapy with clopidogrel for five days prior to surgery with a major risk of bleeding" 4
For patients WITH coronary stents:
Surgery should ideally be postponed beyond 12 months after drug-eluting stent implantation 1, 3
If surgery cannot be delayed, maintain aspirin throughout the perioperative period and minimize the duration of clopidogrel interruption with cardiology guidance 1, 3
D&C-Specific Considerations
D&C is classified as an intermediate-risk bleeding procedure where:
The 5-day discontinuation window is appropriate for patients without stents 3
Bleeding occurs in a relatively accessible space where hemostasis can be achieved 1
This differs from high-risk procedures like intracranial surgery or spinal canal surgery where bleeding in closed spaces poses greater danger 5
Aspirin Management
Continue aspirin 75-100 mg daily throughout the perioperative period if the patient is on dual antiplatelet therapy, as aspirin alone does not significantly increase bleeding risk in most procedures 2, 3
Resumption of Therapy
Restart clopidogrel as soon as adequate hemostasis is achieved postoperatively, typically within 24 hours if no active bleeding 3, 4
The FDA label emphasizes: "Resume clopidogrel as soon as hemostasis is achieved" 4
For high-risk cardiac patients, earlier resumption (within 12-24 hours) may be necessary 5
Critical Pitfalls to Avoid
Never discontinue both aspirin and clopidogrel simultaneously in patients with coronary stents, as this dramatically increases thrombotic risk without proportional bleeding benefit 6
Do not assume all stroke patients are the same: The presence of coronary stents fundamentally changes the risk-benefit calculation 2, 3
Avoid substituting heparin or low-molecular-weight heparin for antiplatelet therapy, as these do not provide protection against coronary artery or stent thrombosis 5
Evidence Quality
The 5-day discontinuation recommendation is supported by ACC/AHA Class I, Level B evidence from multiple guidelines 1. The CURE trial demonstrated that stopping clopidogrel fewer than 5 days before surgery significantly increased major bleeding (9.6% vs 6.3%) with no mortality difference 1. More recent data from the INSPIRES trial showed that dual antiplatelet therapy can be safely initiated up to 72 hours after mild ischemic stroke 7, but this does not change the perioperative discontinuation recommendations for elective procedures.