When is it safe to hold Plavix (clopidogrel) after elective Percutaneous Coronary Intervention (PCI)?

From the Guidelines

After an elective percutaneous coronary intervention (PCI), clopidogrel (Plavix) should typically be continued for at least 6-12 months, depending on the type of stent placed and the patient's bleeding risk. For bare metal stents, a minimum of 1 month of dual antiplatelet therapy (DAPT) with aspirin and clopidogrel is recommended, though 6-12 months is often preferred 1. For drug-eluting stents, at least 6-12 months of DAPT is generally recommended 1. Premature discontinuation of clopidogrel increases the risk of stent thrombosis, which can lead to myocardial infarction or death. If a surgical procedure is necessary during this period, the decision to hold clopidogrel should be made after consulting with both the cardiologist who performed the PCI and the surgeon performing the procedure. For minor procedures with low bleeding risk, clopidogrel may be continued. For procedures with higher bleeding risk, clopidogrel might be held for 5-7 days before surgery, while continuing aspirin if possible 1. The timing of clopidogrel discontinuation should balance the risk of stent thrombosis against the risk of procedural bleeding, with the highest risk of stent thrombosis occurring in the first month after PCI. Some key considerations include:

• The type of stent used: bare metal or drug-eluting
• The patient's bleeding risk: high or low
• The urgency of the surgical procedure: can it be delayed or not
• The risk of stent thrombosis: highest in the first month after PCI It is essential to weigh these factors and make a decision based on the individual patient's needs, taking into account the latest guidelines and evidence-based recommendations 1.

From the Research

Dual Antiplatelet Therapy (DAPT) Duration

• The optimal duration of DAPT after elective percutaneous coronary intervention (PCI) is still a topic of debate 2.
• Extending DAPT beyond 12 months is associated with a reduction in ischemic events but also increased bleeding 2.
• Shortening DAPT (3-6 months) reduces bleeding compared with 1 year of treatment, but it is also probably associated with increased ischemic events, mainly in higher-risk patients undergoing complex PCI 2.

Choice of P2Y12 Inhibitor

• Clopidogrel is the recommended P2Y12 inhibitor in the elective PCI setting 2.
• More potent P2Y12 inhibitors such as ticagrelor or prasugrel may be reasonable in patients with high clinical or angiographic features of increased ischemic risk without increased risk of bleeding 2.
• Prasugrel and ticagrelor have demonstrated greater efficacy than clopidogrel in patients with acute coronary syndrome (ACS) undergoing PCI 3.

Aspirin Discontinuation

• Early aspirin discontinuation at 3 months (and perhaps as early as 1 month) following PCI reduces bleeding, with no evidence to suggest an increase in ischemic events 2.
• Aspirin and ticagrelor for 3 months, followed by aspirin and clopidogrel for the remaining duration, can be considered the optimal strategy for treating post-PCI patients with ACS 4.

Safety of Holding Plavix

• There is no direct evidence on when it is safe to hold Plavix after elective PCI.
• However, the studies suggest that the duration of DAPT should be tailored to individual patient ischemic and bleeding risks 2.
• Clopidogrel was associated with reductions in major adverse cardiac events (MACE) and stroke when compared with aspirin after completing DAPT 5.