Is it safe to take Plavix (clopidogrel) and Aspirin (ASA) after Coronary Artery Bypass Grafting (CABG)?

Dual Antiplatelet Therapy After CABG: Aspirin and Clopidogrel

Dual antiplatelet therapy with aspirin and clopidogrel (Plavix) may be considered after CABG in selected patients at higher risk of graft occlusion and low bleeding risk, but is not routinely recommended for all patients post-CABG. 1

Standard Post-CABG Antiplatelet Recommendations

• Aspirin (100-325 mg daily) should be initiated within 6 hours postoperatively and continued indefinitely to reduce saphenous vein graft closure and adverse cardiovascular events 1
• Aspirin monotherapy is the standard of care for most patients after CABG surgery 1
• For patients who cannot take aspirin due to allergy or intolerance, clopidogrel 75 mg daily is a reasonable alternative 1

When to Consider Dual Antiplatelet Therapy (DAPT)

• DAPT with aspirin plus clopidogrel may be considered in selected patients at higher risk of graft occlusion and low bleeding risk 1
• Factors that may warrant consideration of DAPT include:
  • Patients with higher thrombotic risk profiles 1
  • Patients with radial artery grafts (which may have better patency with DAPT) 2
  • Off-pump CABG procedures (which may benefit more from DAPT than on-pump procedures) 3

Safety Considerations

• The addition of clopidogrel to aspirin increases bleeding risk, which must be weighed against potential benefits 4, 3
• If DAPT is used, consider adding a proton pump inhibitor in patients at increased risk of gastrointestinal bleeding 1
• For elective CABG, clopidogrel should be discontinued at least 5 days before surgery to limit bleeding complications 5
• For urgent CABG, clopidogrel should be discontinued for at least 24 hours before surgery 5

Evidence on DAPT After CABG

• Small studies have shown mixed results regarding the benefit of DAPT on graft patency:
  • Some studies suggest DAPT may improve radial artery graft patency compared to aspirin alone 2
  • Other studies show no significant difference in overall graft patency between clopidogrel plus aspirin versus clopidogrel alone 6
  • The PREVENT IV trial showed no significant improvement in 5-year clinical outcomes with clopidogrel use after CABG 3

Duration of Therapy

• If DAPT is used after CABG, the optimal duration is not clearly established in guidelines 1
• Most studies evaluating DAPT after CABG used treatment durations of 1-3 months 7, 2

Common Pitfalls and Caveats

• Avoid automatically continuing DAPT in all patients after CABG without considering individual risk factors 1
• Do not confuse recommendations for DAPT after PCI (which are stronger) with those after CABG (which are less established) 1
• Remember that bleeding risk increases with DAPT compared to aspirin alone, especially in elderly patients and those with renal dysfunction 4
• For patients with an indication for oral anticoagulation who undergo CABG, different antithrombotic strategies apply and should follow specific guidelines 1