A patient on clopidogrel for a drug-eluting coronary stent placed 6 weeks ago requires an urgent non-cardiac surgical procedure. What is the most appropriate management?

• A Stop clopidogrel 5 days before surgery and proceed
• B Switch to unfractionated heparin and proceed
• C Continue dual antiplatelet therapy; accept increased bleeding risk rather than stent thrombosis risk ✓
• D Perform surgery on aspirin alone; hold clopidogrel 7 days pre-operatively

Explanation

Drug-eluting stents (DES) require dual antiplatelet therapy (DAPT) — aspirin plus P2Y12 inhibitor — for at least 6–12 months (ACC/AHA guidelines; 6 months minimum, 12 months preferred) to prevent catastrophic bare-stent thrombosis. Premature P2Y12 inhibitor discontinuation within this period carries stent thrombosis mortality up to 45%. For truly urgent (non-elective) surgery within 6 months of DES, continue both agents and manage bleeding risk surgically. For elective surgery, defer until DAPT duration is complete. Aspirin monotherapy is insufficient protection against DES thrombosis in this early period.

Reference: Morgan & Mikhail's Clinical Anesthesiology, 6th ed.

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Written and medically reviewed by the StethoPrep medical team.