Aspirin and Clopidegrol : Perioperative Guidelines

The average lifespan of platelets is 7 to 10 days. Aspirin and Clopidegrol inhibits platelets for around 21 days. Hence, when these agents are stopped 7 days before the surgery, it allows 33% regeneration of platelets. Stents and coronary lesions act as unstable plaque until they are completely covered by cellular layer. Bare metal stents require 1 and 1/2 months for being completely covered by smooth muscles and 3 months for the same by endothelium. Drug eluting stents require 1-3 years for complete endothelialization. Aspirin is recommended as a lifelong therapy that should never be interrupted for patients with cardiovascular disease. Clopidogrel therapy is mandatory for six weeks after placement of bare-metal stents, three to six months after myocardial infarction, and at least 12 months after placement of drug-eluting stent. The risk with aspirin withdrawl in rebound phenomenon. Abrupt cessation of aspirin results in an increase in thromboxane A2 activity and a decrease in fibrinolysis, resulting in increased platelet adhesion and aggregation. In addition, the surgical trauma by itself creates a prothrombotic and proinflammatory state, including platelet activation/aggregation and reduced fibrinolytic activity.

preoperative aspirin

A) Primary Aspirin prophylaxis: Treatment with aspirin in the absence of established diagnosis of cardiovascular disease. e.g. for only hypertension or hyperlipidemia

B) Secondary Aspirin prophylaxis: Treatment with aspirin in the presence of overt cardiovascular disease or conditions confering particular risk.

  1. Atrial fibrillation
  2. Angina or previous MI
  3. Stroke
  4. Congestive Heart Failure
  5. CABG, PCI or stenting
  6. Vascular surgery
  7. Non-cardiac stents (carotid, femoral, renal artery stents)
  8. Diabetes mellitus
  9. Renal insufficiency

C) Surgeries with high bleeding risk:

  1. Cardiac surgery
  2. Surgery with massive bleeding
  3. Surgery in a closed space:
    • Intracranial
    • Intramedullary canal
    • Posterior eye chamber
  4. Prostate surgery
  5. Tonsillectomy

D) Current Guideline Recommendations:

1. If the patient is on primary prevention:

  • Interruption of aspirin in primary prevention does not increase the perioperative risk.
  • Stop aspirin and clopidegrol 5 days before surgery if necessary

2. If the patient is on secondary prevention:

  • All elective surgeries must be postponed before the following conditions:
    • 2 weeks of simple dilation
    • 6 weeks of bare metal stenting
    • 12 months of drug-eluting stent placement

In these conditions, if postponement of surgery is not possible:

a. If the patient is planned for high bleeding risk surgery: Stop aspirin and clopidegrol 5 days before surgery

b. If the patient is planned for other surgeries: Continue aspirin and discontinue clopidegrol 5 days before surgery (if intermediate risk of bleeding ) or continue clopidegrol as well (minor risk of bleeding)

  • If the patient is not in high risk for stent thrombosis: Stop both aspirin and clopidegrol for surgeries with high risk of bleeding and Stop only clopidegrol if the surgery doesn’t involve high risk of bleeding.

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