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Perioperative Management of Antiplatelets

 Type of Procedure ASA ASA + Clopidogrel Comments
Minor procedures (dental,eye,skin) Continue Discontinue Clopidogrel 7-10 days prior 2C
Elective non-cardiac surgery-low cardiac risk Discontinue 7-10 days prior Discontinue both 7-10 days prior 2C
Elective non-cardiac surgery-high cardiac risk (exclusive of stents) Continue up to and beyond surgery Continue ASA , discontinue Clopidogrel if safe, resume 24 hrs after surgery (when there is adequate hemostasis) 2C
Cardiac Surgery Continue ASA up to time of CABG, restart 6-48 hours after Discontinue Clopidogrel 5 days prior 2C
Diagnostic procedures-low risk Continue Discontinue Clopidogrel 7-10 days prior to procedure 2C
High risk Discontinue 7-10 days prior Discontinue both 7-10 days prior
Coronary stent- Elective Defer if < 6 weeks after BMS, < 6 months after DES 1C
Coronary stent -Urgent BMS< 6 weeks continue both DES < 6 months continue both 2C
Arthrocentesis Continue Discontinue Clopidogrel 7-10 days prior to procedure 1C

Prasugrel

Prasugrel is often used by cardiologists in the setting of clopidogrel failure.  It is thought to inhibit close to 80% of platelet activity (whereas clopidogrel is in the range of 40-60%).  Given this, the bleeding risk for prasugrel is greater than for clopidogrel and is therefore usually held 10 days prior to surgery.

ASA: Aspirin
CABG: Coronary artery bypass graft
BMS: Bare metal stent
DES: Drug-eluting stent

Strength of the Recommendations Grading System

 

Reference:

Perioperative Management of Antithrombotic Therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141;e326S-350S.

 

UCSD Perioperative Management of Patients with Coronary Stents

Committee Members:

  • Niren Angle, MD
  • Ehtisham Mahmud, MD
  • Gerard Manecke, MD
  • Anushirvan Minokadeh, MD
  • David Roth, MD, PhD
  • Sam Tsimikas, MD

Updated July 2008