When to discontinue Plavix (clopidogrel) before cardiac surgery?

From the Guidelines

Plavix (clopidogrel) should be discontinued at least 5-7 days before elective cardiac surgery to minimize the risk of excessive bleeding, as recommended by the most recent guidelines 1. The decision to discontinue Plavix before cardiac surgery depends on the patient's individual risk factors, including the type of surgery, the presence of recent stent placement, and the patient's overall bleeding and thrombotic risk.

• For elective cardiac surgery, discontinuing Plavix 5-7 days before surgery is generally recommended to allow for adequate recovery of platelet function 1.
• For urgent or emergency cardiac surgery, the timing may be shorter, but ideally at least 24 hours if the clinical situation allows, as suggested by previous guidelines 1. Key considerations in determining the optimal timing for discontinuing Plavix include:
• The patient's bleeding risk versus thrombotic risk
• The type of cardiac surgery being performed
• The presence of recent stent placement or other high-risk factors
• The use of bridging therapy with shorter-acting antiplatelet agents, if necessary It is essential for patients to consult their cardiologist and cardiac surgeon before stopping Plavix, as premature discontinuation in certain situations could increase the risk of stent thrombosis and major cardiac events. The most recent guideline from 2016 1 provides the most up-to-date recommendation for the discontinuation of Plavix before cardiac surgery, superseding previous guidelines from 2011 1 and 2014 1.

From the FDA Drug Label

5.3 Discontinuation of Clopidogrel Discontinuation of clopidogrel increases the risk of cardiovascular events. If clopidogrel must be temporarily discontinued (e.g., to treat bleeding or for surgery with a major risk of bleeding), restart it as soon as possible. When possible, interrupt therapy with clopidogrel for five days prior to such surgery. Resume clopidogrel as soon as hemostasis is achieved.

Discontinuation of Plavix (clopidogrel) before cardiac surgery:

• It is recommended to interrupt therapy with clopidogrel for five days prior to cardiac surgery with a major risk of bleeding.
• Clopidogrel should be restarted as soon as possible after surgery, once hemostasis is achieved 2.

From the Research

Discontinuation of Plavix (Clopidogrel) Before Cardiac Surgery

• The decision to discontinue Plavix (clopidogrel) before cardiac surgery depends on various factors, including the type of surgery, the patient's risk of bleeding and thrombosis, and the timing of the surgery 3, 4, 5, 6, 7.
• According to the study by 3, except for 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.
• The study by 6 suggests that stopping clopidogrel 3 days or less before coronary artery bypass grafting (CABG) may not increase the risk of bleeding, and there was no significant difference in the hemoglobin drop of patients who had clopidogrel stopped 3 days prior to CABG compared to those who stopped 5 days before surgery.
• However, the study by 5 recommends discontinuation of clopidogrel 5 to 7 days prior to surgery or invasive procedures to prevent bleeding complications, and suggests the use of glycoprotein IIb/IIIa inhibitors as "bridging therapy" during the high-risk perioperative period.
• The study by 7 found that patients taking clopidogrel can safely undergo major lung resection, and treatment with an eptifibatide bridge may minimize the risk of cardiovascular events in higher risk patients.

Recommendations for Discontinuation of Plavix (Clopidogrel)

• For elective procedures, surgery should be postponed until the end of the indication for clopidogrel 3.
• Cardiac procedures should be postponed for at least 4 days after clopidogrel withdrawal 3.
• In high-risk patients, bridging therapy with glycoprotein IIb/IIIa inhibitors may be considered during the perioperative period 5, 7.
• The decision to discontinue clopidogrel should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history 3, 4, 5, 6, 7.