Should Plavix (clopidogrel) be stopped before surgery in a patient with a stent placed 3 months ago?

Management of Clopidogrel Before Surgery in a Patient with Recent Stent Placement

Clopidogrel should NOT be stopped before surgery in a patient who received a stent 3 months ago due to the high risk of stent thrombosis, which can lead to significant morbidity and mortality.

Rationale for Continuing Antiplatelet Therapy

The risk of stent thrombosis significantly outweighs the risk of surgical bleeding in most cases. Current guidelines provide clear direction on this matter:

• For patients with drug-eluting stents (DES), dual antiplatelet therapy (DAPT) with aspirin and clopidogrel is recommended for at least 12 months after stent placement 1, 2
• For bare-metal stents (BMS), DAPT is recommended for a minimum of 1 month, but ideally up to 12 months 1
• Premature discontinuation of antiplatelet therapy, especially within the first 6 months after stent placement, is a major predictor of stent thrombosis with a hazard ratio of 13.74 3

Timing Considerations

The 3-month post-stent period is particularly critical:

• For sirolimus-eluting stents, a minimum of 3 months of DAPT is required 1
• For paclitaxel-eluting stents, a minimum of 6 months of DAPT is required 1
• Regardless of stent type, the most recent guidelines recommend 12 months of DAPT for all stented patients who are not at high risk of bleeding 1, 2

Management Algorithm for Surgery with Recent Stent

1. Assess stent thrombosis risk:

   • Stent placed 3 months ago = HIGH RISK
   • Type of stent (DES vs. BMS) affects duration of required DAPT
   • Location of stent (left main, bifurcation, etc.) increases risk

2. Assess bleeding risk of the surgical procedure:

   • High bleeding risk procedures (intracranial, spinal canal, posterior chamber of eye):

     • Consider delaying elective surgery until completion of minimum DAPT duration
     • If surgery cannot be delayed, maintain aspirin and only discontinue clopidogrel 4
     • Resume clopidogrel within 12-24 hours post-operation 4

   • Standard bleeding risk procedures:

     • Continue both aspirin and clopidogrel throughout the perioperative period 4
     • Implement additional hemostatic measures as needed

3. If surgery is urgent/emergent:

   • Continue antiplatelet therapy if at all possible
   • Have platelets available for transfusion if excessive bleeding occurs 4
   • Consider consultation with cardiology, anesthesiology, and surgery to develop a coordinated plan

Special Considerations

• Cardiac surgery: Should be postponed for at least 4 days after clopidogrel withdrawal if absolutely necessary to stop 4
• Regional anesthesia: The thrombotic risk of withdrawing antiplatelet drugs outweighs the benefit of regional or neuraxial blockade 4
• Bridging therapy: Antiplatelet treatment replacement by heparin or LMWH does not provide protection against stent thrombosis 4

Important Caveats

• Premature discontinuation of clopidogrel is associated with significantly higher rates of death and myocardial infarction 3
• Normal hemostasis requires only 20% of circulating platelets to have normal function, so surgical bleeding can often be managed without stopping antiplatelet therapy 4
• Patients should be explicitly instructed never to stop antiplatelet therapy without consulting their cardiologist 2

In conclusion, for a patient with a stent placed 3 months ago, the risk of stent thrombosis from stopping clopidogrel before surgery significantly outweighs the risk of surgical bleeding in most cases. The recommended approach is to continue antiplatelet therapy throughout the perioperative period unless the surgery involves a closed space where bleeding could be catastrophic.