What is the anticoagulation protocol for a patient with a history of coronary artery disease (CAD) and stents, currently on Plavix (clopidogrel), undergoing total hip replacement?

Anticoagulation Protocol for Total Hip Replacement in a Patient with CAD, Stents, and on Plavix

For a patient with coronary artery disease, stents, and currently on Plavix (clopidogrel) undergoing total hip replacement, clopidogrel should be continued perioperatively without interruption while adding appropriate thromboprophylaxis for the orthopedic procedure.

Rationale for Continuing Clopidogrel

The decision to continue clopidogrel during orthopedic surgery is based on balancing the risks:

1. Stent thrombosis risk: Premature discontinuation of clopidogrel in patients with coronary stents significantly increases the risk of stent thrombosis, which carries high mortality and morbidity rates 1.

2. Bleeding risk: While continuing clopidogrel may increase surgical bleeding, this risk is generally manageable and less life-threatening than stent thrombosis.

Management Algorithm

Preoperative Assessment:

• Determine time since stent placement:
  • If stents were placed within the past 12 months, continuing clopidogrel is mandatory 1
  • If stents were placed >12 months ago, continuing clopidogrel is still recommended but with closer monitoring for bleeding

Perioperative Management:

1. Continue clopidogrel 75 mg daily without interruption 1
2. Add thromboprophylaxis for orthopedic surgery:
   • Low molecular weight heparin (LMWH) at prophylactic dose
   • Start 12 hours before or 12 hours after surgery
   • Continue for at least 10-14 days post-surgery

Intraoperative Considerations:

• Inform surgical team about continued clopidogrel therapy
• Use meticulous hemostasis techniques
• Consider cell-salvage techniques if available
• Be prepared for potentially increased blood loss

Postoperative Management:

• Monitor closely for bleeding complications
• Continue clopidogrel without interruption
• Continue thromboprophylaxis for VTE prevention as recommended for total hip replacement
• If significant bleeding occurs, consider:
  • Local hemostatic measures
  • Platelet transfusion only in life-threatening bleeding

Special Considerations

High Bleeding Risk Scenarios:

If the patient has additional high bleeding risk factors (e.g., history of GI bleeding, dual antiplatelet therapy, concomitant anticoagulation):

• Consider consultation with cardiology to discuss risk/benefit of brief clopidogrel interruption
• If interruption is deemed necessary, limit to absolute minimum (3-5 days) 1

Concomitant Aspirin:

• If the patient is on dual antiplatelet therapy (DAPT), consider continuing only clopidogrel and temporarily suspending aspirin if bleeding risk is very high
• Resume aspirin as soon as hemostasis is secured

Evidence Quality and Limitations

The recommendation to continue clopidogrel perioperatively is based on:

• Strong evidence that discontinuation of antiplatelet therapy increases risk of stent thrombosis 1
• Recognition that bleeding complications, while increased, are generally manageable
• European Society of Cardiology guidelines that prioritize prevention of stent thrombosis 1

Common Pitfalls to Avoid

1. Discontinuing clopidogrel too early before surgery - this significantly increases stent thrombosis risk
2. Failing to communicate with the surgical team about continued antiplatelet therapy
3. Not having a plan for managing potential bleeding complications
4. Delaying resumption of antiplatelet therapy after surgery if temporarily discontinued

By continuing clopidogrel throughout the perioperative period and adding appropriate VTE prophylaxis, you provide the best protection against both stent thrombosis and venous thromboembolism while accepting a manageable increase in bleeding risk.