Perioperative Management of Clopidogrel (Plavix) in Patients with Cardiac Stents
For patients with cardiac stents, clopidogrel (Plavix) should be discontinued for at least 5 days and preferably 7 days before elective procedures, unless the urgency for the procedure outweighs the risks of excess bleeding. 1
Timing of Discontinuation Based on Stent Type and Placement Time
The decision to hold clopidogrel depends on the type of stent and time since placement:
High Thrombotic Risk (Do NOT discontinue clopidogrel)
- Bare metal stents (BMS) placed within the last 30 days 1, 2
- Drug-eluting stents (DES) placed within the last 3-12 months 1, 3, 2
- Recent acute coronary syndrome within 12 months 1
In these high-risk scenarios, elective procedures should be postponed if possible. If the procedure is urgent:
- Continue aspirin throughout the perioperative period 1, 4
- Consider consulting cardiology for risk assessment
Moderate to Low Thrombotic Risk (Can temporarily discontinue)
For these patients:
- Stop clopidogrel 5-7 days before surgery 1
- Continue aspirin if possible 4
- Resume clopidogrel as soon as hemostasis is achieved, ideally within 24 hours 5, 6
Procedure-Specific Considerations
The bleeding risk of the procedure should be considered:
Low Bleeding Risk Procedures
- Continue dual antiplatelet therapy 7
- Examples: diagnostic endoscopy, minor dermatologic procedures, cataract surgery
Moderate to High Bleeding Risk Procedures
- Discontinue clopidogrel for 5-7 days 1
- Continue aspirin when possible 4
- Examples: major abdominal surgery, orthopedic surgery, neurosurgery
Closed Space Procedures (Very High Bleeding Risk)
- Discontinue clopidogrel for 5-7 days 1, 4
- Consider discontinuing aspirin as well 4
- Examples: intracranial surgery, spinal canal procedures, posterior chamber eye surgery
Resumption of Clopidogrel After Procedures
The timing of clopidogrel resumption is critical:
- High thrombotic risk patients: Resume within 12-24 hours after procedure 5, 4
- Moderate thrombotic risk: Resume within 24-48 hours 5
- Low thrombotic risk: Resume within 24-72 hours 5
Consider a loading dose (300-600mg) when resuming clopidogrel to achieve faster platelet inhibition, especially in high-risk patients 6, 7
Important Caveats
- Never substitute heparin or low-molecular-weight heparin for antiplatelet therapy as they do not provide protection against stent thrombosis 4
- The risk of stent thrombosis after antiplatelet discontinuation is generally higher than the risk of surgical bleeding when continuing therapy 3, 4
- If bleeding occurs during a procedure, platelet transfusion may be necessary as the antiplatelet effects of clopidogrel are irreversible 6
- The FDA label specifically states: "When possible, interrupt therapy with clopidogrel for five days prior to surgery with a major risk of bleeding. Resume clopidogrel as soon as hemostasis is achieved." 6
Conclusion
The perioperative management of clopidogrel requires careful consideration of both thrombotic and bleeding risks. The timing since stent placement is the most critical factor in determining whether clopidogrel can be safely discontinued.