What is the recommended duration of Plavix (clopidogrel) therapy after a Watchman procedure?

Duration of Plavix (Clopidogrel) After Watchman Procedure

Patients should receive clopidogrel (Plavix) for 6 months after Watchman device implantation, following an initial 45-day period of oral anticoagulation with warfarin. 1

Standard Post-Watchman Antithrombotic Regimen

The recommended medication regimen following Watchman implantation follows a specific timeline:

1. 0-45 days post-procedure:

   • Warfarin (target INR 2.0-3.0) plus aspirin (81-100mg daily)
   • Transesophageal echocardiogram (TEE) at 45 days to assess for device-related thrombus and peri-device leakage

2. 45 days to 6 months:

   • Discontinue warfarin if TEE shows:
     • No device-related thrombus
     • Minimal residual peri-device flow (≤5mm)
   • Begin dual antiplatelet therapy (DAPT):
     • Aspirin (81-100mg daily)
     • Clopidogrel (75mg daily)

3. After 6 months:

   • Discontinue clopidogrel
   • Continue aspirin (81-100mg) indefinitely 1, 2

Special Considerations and Variations

Patients with Contraindications to Oral Anticoagulation

For patients with absolute contraindications to oral anticoagulation (the primary population for whom Watchman is indicated):

• Some evidence suggests using dual antiplatelet therapy (aspirin plus clopidogrel) for the first 6 months, followed by aspirin indefinitely 2, 3
• This approach may be considered when warfarin cannot be used, though it carries a theoretical increased risk of device-related thrombus 3

Device-Related Thrombus Management

If device-related thrombus is detected:

• Consider switching to a direct oral anticoagulant (DOAC) like apixaban
• Case reports show successful resolution of device-related thrombus with apixaban 4
• After thrombus resolution, patients may return to the standard antiplatelet regimen

Early Discontinuation Considerations

Some retrospective studies have examined shortened periods of anticoagulant and antiplatelet therapy:

• In high bleeding risk patients, 70.2% discontinued anticoagulation at 45 days and 89.4% discontinued DAPT by 90 days without significant differences in stroke-free survival 3
• However, these are small retrospective studies and should not override the standard recommendation

Monitoring Requirements

• TEE at 45 days is mandatory to assess for:
  • Device position and stability
  • Presence of device-related thrombus
  • Peri-device leakage (should be ≤5mm to discontinue warfarin)
• Additional TEE at 6 months may be performed to confirm continued proper device function before discontinuing clopidogrel 1, 5

Risks of Premature Discontinuation

Premature discontinuation of antiplatelet therapy increases the risk of:

• Device-related thrombus (approximately 3.4% of patients)
• Thromboembolic events
• Stroke 1, 2

Conclusion

The standard duration of clopidogrel (Plavix) after Watchman implantation is 6 months (from day 45 to month 7.5 post-procedure), following an initial 45-day period of oral anticoagulation. This regimen has been established through clinical trials and is reflected in current practice guidelines, though individualization may be necessary for patients with specific bleeding risks or contraindications to anticoagulation.