How soon can Plavix (clopidogrel) be held before a procedure in a patient who has undergone angioplasty without stent placement?

Holding Clopidogrel After Angioplasty Without Stent Placement

For patients who have undergone angioplasty without stent placement, clopidogrel can be discontinued immediately before a procedure as there is no specific guideline-recommended duration of mandatory dual antiplatelet therapy in this scenario, unlike with stent placement. 1

Rationale for Discontinuation Timing

• The mandatory dual antiplatelet therapy recommendations primarily apply to patients who have received coronary stents, with durations of at least 1 month for bare-metal stents and at least 12 months for drug-eluting stents 1
• Without stent placement, the risk of thrombosis at the angioplasty site is significantly lower than with stents, which require endothelialization 2
• The FDA label for clopidogrel states that when temporary discontinuation is necessary, the medication should be restarted as soon as possible after the procedure 2

Timing Considerations for Different Procedures

For Surgical Procedures:

• If the upcoming procedure carries significant bleeding risk (especially in closed spaces):
  • Discontinue clopidogrel at least 5 days before elective surgery 3, 1
  • Preferably discontinue 7 days before surgery for optimal platelet function recovery 1, 4
• For urgent surgical procedures:
  • A minimum of 24 hours discontinuation is recommended, though this carries increased bleeding risk 3, 5

For Non-Surgical Procedures:

• For low bleeding risk procedures (e.g., dental work, skin biopsies):
  • Clopidogrel can be continued throughout the procedure 6
• For moderate bleeding risk procedures:
  • Consider discontinuing 3 days before the procedure 5

Bleeding Risk Considerations

• Patients who undergo surgery while on clopidogrel within 3 days have:

  • Increased blood transfusion requirements 5
  • Higher chest tube drainage (1485 ml vs 780 ml) 4
  • Higher re-exploration rates for bleeding (5.9% vs 1.2%) 4

• For peripheral arterial surgery specifically, some evidence suggests continuing clopidogrel may be safe 7, but this is procedure-specific and not generalizable to all surgeries

Important Caveats

• The decision to discontinue clopidogrel should balance thrombotic risk against bleeding risk 3
• If the patient had angioplasty for acute coronary syndrome, they may still benefit from continued clopidogrel therapy for 12 months even without stent placement 1
• For patients with high thrombotic risk but requiring surgery, consider:
  • Delaying elective procedures when possible 8
  • Consulting with the patient's cardiologist before discontinuing clopidogrel 1
  • Resuming clopidogrel as soon as hemostasis is achieved after the procedure 3, 2

Special Considerations

• If the patient is on dual antiplatelet therapy for other indications (e.g., recent MI, stroke, peripheral arterial disease), these indications should be considered when deciding on discontinuation 2
• For procedures with minimal bleeding risk, continuing clopidogrel may be safer than risking thrombotic complications from discontinuation 6
• For procedures with high bleeding risk in closed spaces (intracranial, spinal), clopidogrel should be discontinued for the full 5-7 days 1, 3