How long to hold Plavix (clopidogrel)?

From the Guidelines

Plavix (clopidogrel) should be withheld for at least 5 days before surgery in patients undergoing elective CABG. This recommendation is based on the 2011 ACCF/AHA guideline for coronary artery bypass graft surgery, which suggests that in patients taking thienopyridines (clopidogrel or prasugrel) or ticagrelor, clopidogrel and ticagrelor should be withheld for at least 5 days and prasugrel for at least 7 days before surgery 1. When considering the management of antiplatelet therapy in patients undergoing CABG, it is crucial to balance the risk of bleeding against the risk of thrombotic events.

• The decision to hold Plavix should be made on a case-by-case basis, taking into account the individual patient's risk factors and the urgency of the surgery.
• In general, the guideline recommends a multimodal approach to limit the number of transfusions and reduce perioperative blood loss, including the use of lysine analogues and a focused blood conservation strategy 1.
• It is also important to note that other antiplatelet agents, such as tirofiban or eptifibatide, should be discontinued at least 2 to 4 hours before CABG, and abciximab at least 12 hours before CABG 1.
• Ultimately, the management of antiplatelet therapy in patients undergoing CABG requires careful consideration of the potential risks and benefits, and should be guided by the most recent and highest-quality evidence available 1.

From the Research

Duration of Plavix (Clopidogrel) Hold Before Surgery

• The optimal duration for holding Plavix (clopidogrel) before surgery is a topic of ongoing research, with various studies providing insights into the risks and benefits of different hold times 2, 3, 4, 5, 6.
• A common recommendation is to stop clopidogrel 5 to 7 days before coronary artery bypass surgery to minimize the risk of post-operative bleeding 2.
• However, some studies suggest that stopping clopidogrel 3 days or less before surgery may not significantly increase the risk of bleeding complications 3.
• In patients with acute coronary syndrome undergoing coronary artery bypass surgery, continuing clopidogrel within 5 days before surgery was associated with increased odds of major cardiac and cerebrovascular events and bleeding complications 5.
• The risk of bleeding complications may be higher in patients older than 65 years who continue clopidogrel within 5 days before surgery 5.
• In patients treated with ticagrelor or clopidogrel, there was no significant difference in major bleeding complications when the medication was discontinued 5 days or more before surgery 6.
• However, when ticagrelor or clopidogrel was discontinued 0-1 day before surgery, there was a trend towards higher incidence of major bleeding in ticagrelor-treated patients 6.

Key Findings

• Stopping clopidogrel 5 to 7 days before surgery may minimize the risk of post-operative bleeding 2.
• Stopping clopidogrel 3 days or less before surgery may not significantly increase the risk of bleeding complications 3.
• Continuing clopidogrel within 5 days before surgery may increase the risk of major cardiac and cerebrovascular events and bleeding complications in patients with acute coronary syndrome 5.

Considerations for Hold Time

• The decision to hold clopidogrel before surgery should be individualized based on the patient's risk of bleeding and thrombotic events 3, 5, 6.
• Careful attention should be paid to meticulous hemostasis, and platelets should be readily available for transfusion in the operating room 4.