Can you take Plavix (clopidogrel) and Eliquis (apixaban) prior to an angiogram?

Management of Plavix and Eliquis Prior to Angiogram

Clopidogrel (Plavix) should be continued before an angiogram, but apixaban (Eliquis) should be discontinued at least 48 hours prior to the procedure due to bleeding risk. 1, 2

Antiplatelet Management (Plavix/Clopidogrel)

• For patients undergoing diagnostic angiography, clopidogrel can be safely continued prior to the procedure 1
• If the patient is already on clopidogrel therapy for a valid indication (such as recent stent placement or acute coronary syndrome), continuing the medication is recommended to prevent thrombotic complications 1
• In fact, for patients who may need percutaneous coronary intervention (PCI) following angiography, guidelines specifically recommend administering a loading dose of clopidogrel if not already on therapy 1
• Studies have shown no significant benefit in delaying angiography after clopidogrel loading, suggesting the medication can be safely continued up to the time of the procedure 3, 4

Anticoagulant Management (Eliquis/Apixaban)

• Apixaban (Eliquis) should be discontinued at least 48 hours prior to elective angiography or other invasive procedures with moderate to high risk of bleeding 2
• For procedures with low bleeding risk, apixaban should be discontinued at least 24 hours prior 2
• According to the FDA drug label, "Apixaban tablets should be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding" 2
• Unlike heparin products, bridging anticoagulation during the 24-48 hours after stopping apixaban and prior to the procedure is not generally required 2, 5

Special Considerations

• If the angiogram is being performed for acute coronary syndrome (ACS) and the patient is on dual antiplatelet therapy:

  • Continue aspirin therapy 1
  • Continue clopidogrel if already started 1
  • Discontinue apixaban as noted above 2

• For patients with high thrombotic risk (recent stent placement, mechanical heart valve):

  • The decision to discontinue apixaban should be made after careful consideration of thrombotic versus bleeding risk 2, 5
  • Consultation with both the cardiologist performing the angiogram and the provider who prescribed the anticoagulation is recommended 5

Post-Procedure Management

• Apixaban should be restarted after the angiogram as soon as adequate hemostasis has been established 2
• If PCI is performed following angiography:
  • Continue clopidogrel therapy 1
  • The decision to restart apixaban will depend on the type of intervention performed and should be individualized based on thrombotic and bleeding risks 2

Common Pitfalls to Avoid

• Do not confuse recommendations for diagnostic angiography with those for coronary artery bypass grafting (CABG) - CABG requires discontinuation of clopidogrel 5-7 days prior 1, 6
• Do not automatically discontinue all antithrombotic medications before angiography - this could increase thrombotic risk 1, 7
• Remember that the risk of bleeding during diagnostic angiography alone is generally lower than the risk of thrombotic events if antiplatelet therapy is discontinued, especially in high-risk patients 7