How long is Plavix (clopidogrel) recommended after Coronary Artery Bypass Grafting (CABG)?

Duration of Plavix (Clopidogrel) After CABG

In patients who have undergone CABG, P2Y12 inhibitor therapy (clopidogrel) should be resumed postoperatively and continued for 12 months to complete the recommended duration of dual antiplatelet therapy (DAPT). 1

General Recommendations for DAPT After CABG

• In patients with Acute Coronary Syndrome (ACS) being treated with DAPT who undergo CABG, P2Y12 inhibitor therapy should be resumed after surgery to complete 12 months of DAPT therapy after the ACS 1
• For patients with stable ischemic heart disease (SIHD), DAPT with clopidogrel initiated early postoperatively for 12 months after CABG may be reasonable to improve vein graft patency 1
• The Heart Team should estimate the individual bleeding and ischemic risks to guide the timing of CABG and antithrombotic management 1

Specific Timing Considerations

Before CABG:

• P2Y12 inhibitors should be discontinued before non-emergent cardiac surgery to reduce bleeding risk:
  • Ticagrelor: at least 3 days before surgery 1
  • Clopidogrel: at least 5 days before surgery 1
  • Prasugrel: at least 7 days before surgery 1

After CABG:

• Aspirin should be continued throughout the perioperative period at a low daily regimen 1
• P2Y12 inhibitor therapy should be resumed as soon as it is deemed safe post-operatively 1, 2
• The most common practice is to initiate clopidogrel on day 1 after surgical revascularization 3

Duration Based on Clinical Scenario

For patients with ACS who undergo CABG:

• P2Y12 inhibitor should be resumed after CABG to complete a full 12-month course of DAPT 1
• This recommendation is consistent across both American and European guidelines 1

For patients with SIHD who undergo CABG:

• DAPT with clopidogrel for 12 months after CABG may be reasonable to improve vein graft patency 1
• Studies have shown that combined aspirin and clopidogrel therapy increases early venous graft patency compared to aspirin alone 4

For patients at high risk of bleeding:

• In CABG patients with prior MI who are at high risk of severe bleeding, discontinuation of P2Y12 inhibitor therapy after 6 months should be considered 1
• The bleeding risk must be balanced against the ischemic risk when determining DAPT duration 1

Common Pitfalls and Caveats

• Failure to resume P2Y12 inhibitor therapy post-operatively may increase the risk of graft occlusion and adverse cardiovascular events 2, 4
• Continuing DAPT too close to surgery increases the risk of postoperative bleeding, myocardial infarction, and reoperation for bleeding 5
• There is considerable variation in practice regarding DAPT after CABG, highlighting the need for standardized protocols 3
• Platelet function testing may be considered to guide decisions on timing of CABG in patients who have recently received P2Y12 inhibitors 1

Choice of P2Y12 Inhibitor

• Clopidogrel is the most commonly used P2Y12 inhibitor after CABG, used by 75% of surgeons according to UK survey data 3
• For patients with ACS, ticagrelor or prasugrel may be preferred over clopidogrel if there are no contraindications 1
• However, these more potent agents carry an increased risk of bleeding compared to clopidogrel 1

In summary, while individual patient factors should be considered, the standard recommendation is to continue Plavix (clopidogrel) for 12 months after CABG, particularly in patients who had an ACS prior to surgery.