Should Plavix (clopidogrel) be discontinued in a patient with recent cardiac stents undergoing hysteroscopy?

From the Guidelines

No, you should not stop Plavix (clopidogrel) for a patient with recent cardiac stents who is undergoing hysteroscopy. Hysteroscopy is considered a low bleeding risk procedure, and the risk of stent thrombosis from discontinuing antiplatelet therapy outweighs the bleeding risk 1. The patient should continue their regular dose of Plavix without interruption throughout the perioperative period. If the patient is on dual antiplatelet therapy (DAPT) with both Plavix and aspirin, both medications should be continued.

Key Considerations

• The risk of stent thrombosis is higher when antiplatelet therapy is discontinued, especially in the first few months after stent placement 1.
• The benefits of continuing antiplatelet therapy outweigh the risks of bleeding in most cases, especially for low-risk procedures like hysteroscopy 1.
• Coordination with the patient's cardiologist is essential to determine the best course of action, especially if the stent placement was recent.

Management Recommendations

• Continue Plavix and aspirin (if on DAPT) without interruption throughout the perioperative period.
• Employ meticulous surgical technique to minimize bleeding during the procedure.
• Be prepared to manage any bleeding that may occur during or after the procedure.
• Consider delaying the procedure if possible, to allow for at least partial endothelialization of the stent, which generally takes 4 to 6 weeks 1.

Outcome Prioritization

The primary concern is to minimize the risk of stent thrombosis and subsequent morbidity and mortality, while also considering the risk of bleeding complications. The most recent and highest quality study 1 supports continuing antiplatelet therapy in patients with recent cardiac stents undergoing non-cardiac surgery, including low-risk procedures like hysteroscopy.

From the Research

Perioperative Management of Patients with Coronary Stents

• The management of patients with coronary stents undergoing non-cardiac surgery, such as hysteroscopy, requires careful consideration of the risks of bleeding and stent thrombosis 2, 3.
• Dual antiplatelet therapy, including clopidogrel and aspirin, is essential for preventing stent thrombosis, especially in patients with drug-eluting stents 2, 3, 4, 5.
• The duration of antiplatelet therapy varies depending on the type of stent, with bare metal stents typically requiring 3-4 weeks of therapy and drug-eluting stents requiring 6-12 months 2.

Risks of Discontinuing Clopidogrel

• Discontinuing clopidogrel increases the risk of stent thrombosis, which can be life-threatening 3, 4, 5.
• Premature cessation of clopidogrel has been associated with increased mortality and major adverse cardiac events in patients with drug-eluting stents 5.
• The risk of stent thrombosis is higher in patients with drug-eluting stents than in those with bare metal stents 4, 5.

Balancing Risks in the Perioperative Period

• The decision to discontinue clopidogrel in a patient with a recent cardiac stent undergoing hysteroscopy should be made on a case-by-case basis, taking into account the individual's risk of bleeding and stent thrombosis 2, 3, 6.
• A collaborative approach between the anesthesiologist, cardiologist, and surgeon is essential for determining the best course of action 2, 3.
• In general, aspirin should be continued until the day of surgery, and clopidogrel should be discontinued only if the risk of bleeding is high 2.