What is the recommended management for a patient with a history of stent placement who is currently taking Plavix (clopidogrel)?

Management of Patients with History of Coronary Stent on Clopidogrel

For patients with coronary stents placed many years ago who are currently on clopidogrel (Plavix), continuation of antiplatelet therapy should be based on stent type, with indefinite low-dose aspirin therapy recommended for all patients while clopidogrel can be discontinued after the minimum required duration has passed.

Duration of Antiplatelet Therapy Based on Stent Type

Bare Metal Stents (BMS)

• Clopidogrel 75 mg daily should be continued for a minimum of 1 month after BMS implantation 1
• If the stent was placed many years ago (>1 year), clopidogrel can be safely discontinued 1
• Low-dose aspirin (75-162 mg daily) should be continued indefinitely 1

Drug-Eluting Stents (DES)

• For first-generation DES:
  • Sirolimus-eluting stents: minimum 3 months of clopidogrel 1
  • Paclitaxel-eluting stents: minimum 6 months of clopidogrel 1
• For all DES types, ideally continue clopidogrel for 12 months if not at high risk of bleeding 1
• After 12 months post-DES placement, clopidogrel can be discontinued if no complications have occurred 2
• Low-dose aspirin (75-162 mg daily) should be continued indefinitely 1

Special Considerations

Risk Assessment for Discontinuation

Before discontinuing clopidogrel in a patient with a history of stent placement, consider:

1. Risk factors for late stent thrombosis 3:

   • Diabetes mellitus
   • Renal failure
   • History of bifurcation lesions
   • Prior in-stent restenosis

2. Bleeding risk factors:

   • Advanced age
   • History of GI bleeding
   • Concurrent anticoagulation
   • Chronic alcohol use
   • Anemia 1

Perioperative Management

If the patient requires surgery:

• For patients with stents placed many years ago (>1 year), it is generally safe to proceed with surgery while maintaining aspirin therapy 1
• Clopidogrel can be discontinued 5 days before surgery if necessary 4
• Resume clopidogrel as soon as hemostasis is achieved post-surgery 4
• For high bleeding risk procedures (intracranial, spinal, posterior chamber of eye), both antiplatelet agents may need to be temporarily discontinued 5

Triple Therapy (When Anticoagulation is Required)

If the patient requires anticoagulation (e.g., for atrial fibrillation):

• For patients with stents placed many years ago, consider:
  • Dual therapy with OAC plus clopidogrel 75 mg daily rather than triple therapy 1
  • If triple therapy is needed, limit duration to shortest time possible 1
  • Target INR 2.0-2.5 if warfarin is used with antiplatelet therapy 1
  • Consider using NOAC instead of warfarin when appropriate 1
  • Use proton pump inhibitor for GI protection 1

Common Pitfalls to Avoid

1. Premature discontinuation: Stopping clopidogrel too early (especially <12 months after DES placement) significantly increases risk of stent thrombosis and mortality 3

2. Failure to maintain aspirin: Even after clopidogrel is discontinued, lifelong aspirin therapy (75-162 mg daily) should be maintained unless absolutely contraindicated 1

3. Inadequate perioperative management: Discontinuing both antiplatelet agents simultaneously for elective procedures within the first year after stenting can lead to catastrophic stent thrombosis 1

4. Drug interactions: Avoid strong CYP2C19 inhibitors (e.g., omeprazole) which can reduce clopidogrel's effectiveness 4

5. Ignoring bleeding symptoms: Failure to address bleeding complications promptly can lead to serious adverse outcomes 4

In summary, for patients with coronary stents placed many years ago who are currently on clopidogrel, it is generally safe to discontinue clopidogrel while maintaining lifelong low-dose aspirin therapy, provided the minimum required duration of dual antiplatelet therapy has been completed based on the stent type.