Perioperative Management of Aspirin and Clopidogrel

Aspirin Management

The American College of Chest Physicians recommends stopping aspirin ≤7 days before surgery in patients at low cardiovascular risk, but continuing perioperatively in patients at moderate-to-high cardiovascular risk 1, 2
For patients receiving aspirin for secondary prevention of cardiovascular disease, continue aspirin throughout the perioperative period, including those with prior myocardial infarction, prior stroke, and coronary stents 1, 3
Continue aspirin for CABG surgery, as recommended by the American College of Chest Physicians 3, 4
For low cardiovascular risk patients, stop aspirin ≤7 days before surgery, as updated by the 2022 American College of Chest Physicians guidelines 1, 5
For minor procedures such as dental procedures, dermatologic procedures, and cataract surgery, continue aspirin regardless of cardiovascular risk 3, 4

Stop clopidogrel 5 days before surgery in most circumstances, as recommended by the American College of Chest Physicians 2, 3
For patients with coronary stents, defer elective surgery for at least 6 weeks after bare-metal stent placement and 6 months after drug-eluting stent placement, and continue dual antiplatelet therapy perioperatively if surgery cannot be deferred 3, 4
After 6 months post-drug-eluting stent, continue aspirin but stop clopidogrel 5 days before surgery, as recommended by the American College of Chest Physicians 3

Resume both aspirin and clopidogrel within 24 hours after surgery when adequate hemostasis is achieved, as recommended by the American College of Chest Physicians 1, 2, 5
Consider a 300 mg loading dose of clopidogrel when resuming therapy in patients with drug-eluting stents, as suggested by some experts 2

Discontinuing aspirin too early, using the outdated 7-10 day window, which unnecessarily prolongs the period of increased thrombotic risk 1, 5
Inadequate medication reconciliation, including failure to report over-the-counter NSAIDs with antiplatelet effects, which can increase bleeding risk 2, 5
Combining multiple antiplatelet or anticoagulant medications, which increases bleeding risk, and carefully assessing the cumulative bleeding risk in these patients 2, 5

The European Society of Cardiology recommends assessing thrombotic risk by determining time since stent placement, stent type, and indication for DAPT (acute coronary syndrome vs. stable disease) 6, 7
The American College of Cardiology suggests assessing bleeding risk by identifying if surgery is high-risk (intracranial, spinal, posterior chamber eye surgery) versus standard risk 6, 8
A multidisciplinary team, including cardiology, surgery, and anesthesia, should convene to determine optimal timing and management strategy, as recommended by the European Heart Journal 6, 9

The European Heart Journal recommends continuing aspirin perioperatively in the vast majority of cases, including all patients with coronary stents 6, 9
The American College of Cardiology suggests stopping the P2Y12 inhibitor based on specific agent, with ticagrelor stopped 3-5 days before surgery, clopidogrel stopped 5 days before surgery, and prasugrel stopped 7 days before surgery 6, 9

The European Society of Anaesthesiology states that aspirin alone is not a contraindication to neuraxial anesthesia if no other hemostatic abnormalities exist 8, 10
The American Society of Regional Anesthesia and Pain Medicine recommends that any P2Y12 inhibitor is an absolute contraindication to central neuraxial blocks unless discontinued for full duration 8, 10

The European Heart Journal recommends resuming antiplatelet therapy within 24 hours after surgery when adequate hemostasis is achieved 6, 9
The American College of Cardiology suggests resuming aspirin at maintenance dose (75-100 mg daily) and P2Y12 inhibitors at standard dosing 6, 11

The European Association for Cardio-Thoracic Surgery recommends continuing aspirin throughout the perioperative period for CABG 11, 12
The Society of Thoracic Surgeons suggests discontinuing P2Y12 inhibitor, with clopidogrel stopped 5 days, ticagrelor stopped 3 days minimum, and prasugrel stopped 7 days before surgery 9, 11