Can a patient with a recent stent placement to the proximal Left Anterior Descending (LAD) artery hold Plavix (clopidogrel) for an Esophagogastroduodenoscopy (EGD)?

Management of Clopidogrel (Plavix) for a Patient with Recent LAD Stent Undergoing EGD

Clopidogrel (Plavix) should not be held for an EGD in a patient with a recent proximal LAD stent placed in June (within the last 12 months). 1

Rationale for Continuing Dual Antiplatelet Therapy

• Patients with recent coronary stent placement, particularly in the proximal LAD (a high-risk location), require uninterrupted dual antiplatelet therapy (DAPT) to prevent stent thrombosis, which carries high morbidity and mortality 1
• For patients with drug-eluting stents (DES), guidelines recommend DAPT with aspirin and clopidogrel for a minimum of 12 months after stent placement 1
• Even for bare-metal stents (BMS), DAPT is recommended for at least 1 month and ideally up to 12 months 1
• Premature discontinuation of clopidogrel is a major predictor of stent thrombosis (hazard ratio = 13.74) 2

Risk Assessment for This Patient

• Proximal LAD stents are considered high-risk due to the large territory of myocardium at risk if stent thrombosis occurs 1
• The risk of stent thrombosis is highest within the first 6-12 months after stent placement 1
• The risk of serious bleeding during EGD while on DAPT is generally lower than the risk of stent thrombosis if antiplatelet therapy is interrupted 1

Recommended Approach

1. Continue clopidogrel without interruption for the EGD procedure 1
2. Continue aspirin therapy as well (typically 81 mg daily) 1
3. Inform the gastroenterologist about the recent stent placement and the critical importance of maintaining DAPT 1
4. Consider the following risk-reduction strategies for the EGD:
   • Have an experienced endoscopist perform the procedure 1
   • Avoid biopsies unless absolutely necessary 1
   • Use caution with polypectomy or other interventional procedures 1
   • Have appropriate hemostatic tools available during the procedure 1

Important Considerations

• The risk of stent thrombosis far outweighs the bleeding risk of diagnostic EGD in patients with recent coronary stents 1
• If the EGD is purely diagnostic without planned biopsies or interventions, the bleeding risk is minimal even on DAPT 1
• If therapeutic intervention is planned during EGD that significantly increases bleeding risk, consider:
  • Postponing the EGD until after completion of the minimum required DAPT duration if clinically feasible 1
  • Consulting with both cardiology and gastroenterology to develop a coordinated plan if the procedure cannot be delayed 1

Common Pitfalls to Avoid

• Discontinuing clopidogrel prematurely increases the risk of stent thrombosis, which can lead to myocardial infarction or death 2
• Failure to recognize the high-risk nature of proximal LAD stents 1
• Not communicating effectively between cardiology and gastroenterology about the management plan 1
• Assuming all endoscopic procedures carry the same bleeding risk (diagnostic EGD has lower risk than therapeutic procedures) 1

In summary, for a patient with a recent proximal LAD stent placed in June, clopidogrel should be continued for the EGD procedure to prevent the potentially catastrophic complication of stent thrombosis. The bleeding risk of diagnostic EGD is low and is outweighed by the risk of stent thrombosis if antiplatelet therapy is interrupted.