From the Guidelines
Clopidogrel (Plavix) is typically not held before a diagnostic cardiac catheterization but should be continued for patients with acute coronary syndrome or those with recent coronary stent placement. However, if the catheterization might lead to urgent cardiac surgery, Plavix is often held for 5-7 days before the procedure to reduce bleeding risk, as recommended by the 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes 1. For elective procedures where coronary intervention is anticipated, Plavix is usually continued or even initiated with a loading dose of 300-600mg beforehand. The decision ultimately depends on the patient's specific clinical situation, including their thrombotic risk versus bleeding risk.
- Patients with drug-eluting stents placed within the past 6-12 months or bare metal stents within 1 month are at particularly high risk for stent thrombosis if Plavix is discontinued.
- For patients on Plavix for secondary stroke prevention or peripheral arterial disease, the medication can typically be held for 5 days before procedures with high bleeding risk, though this should be determined on a case-by-case basis in consultation with the patient's cardiologist, as suggested by the 2011 ACCF/AHA guideline for coronary artery bypass graft surgery 1 and the 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction 1.
From the FDA Drug Label
Talk with your doctor about stopping your clopidogrel tablets before you have surgery. Your doctor may tell you to stop taking clopidogrel tablets at least 5 days before you have surgery to avoid excessive bleeding during surgery.
It is recommended to hold clopidogrel (Plavix) before a cath procedure, but the decision should be made by the doctor, and the typical hold time is at least 5 days before surgery to avoid excessive bleeding during surgery 2 2.
From the Research
Perioperative Management of Plavix (Clopidogrel)
The management of patients on Plavix (clopidogrel) before undergoing catheterization or surgery is a complex issue, with various studies providing insights into the risks and benefits of continuing or discontinuing antiplatelet therapy.
- The risk of bleeding associated with continuing clopidogrel must be weighed against the risk of thrombosis if the medication is discontinued 3, 4.
- Some studies suggest that, except in low-risk settings, the practice of withdrawing antiplatelet drugs 5-10 days prior to surgical procedures should be changed, and most surgical procedures may be performed while on low-dose aspirin treatment 4.
- For patients undergoing noncardiac procedures, clopidogrel should not be discontinued before surgery if prescribed for acute coronary syndrome or during stent re-endothelialization 4.
- In selected patients, some thoracic surgical procedures can be performed safely on clopidogrel, but are associated with higher rates of postoperative transfusion 5.
- Tranexamic acid has been shown to reduce bleeding and transfusion requirements in patients receiving coronary artery bypass grafting (CABG) who are exposed to clopidogrel 6, 7.
Specific Considerations for Catheterization
- The decision to hold Plavix before catheterization should be made on an individual basis, taking into account the patient's specific clinical situation and the risks and benefits of continuing or discontinuing antiplatelet therapy 3, 4.
- There is no one-size-fits-all approach to managing patients on Plavix before catheterization, and the best course of action will depend on various factors, including the patient's medical history, the type of procedure being performed, and the potential risks and benefits of continuing or discontinuing antiplatelet therapy.
- Some studies suggest that continuing clopidogrel throughout the perioperative period may be associated with a higher risk of bleeding, but may also reduce the risk of thrombotic events 5.