Is it okay to start tinzaparin (Low Molecular Weight Heparin) and Plavix (Clopidogrel) after Coronary Artery Bypass Grafting (CABG) while still on Continuous Telemetry (CTT)?

Management of Tinzaparin and Clopidogrel After CABG While on Continuous Telemetry

It is not recommended to start both tinzaparin (LMWH) and clopidogrel (Plavix) immediately after CABG while the patient is still on continuous telemetry due to significantly increased bleeding risk. 1

Post-CABG Antithrombotic Management

Recommended Approach

• Aspirin 75-100 mg daily is the recommended lifelong antiplatelet therapy after CABG and should be initiated as soon as there is no concern over bleeding 1
• Aspirin should be restarted as soon as possible after CABG, potentially within 24 hours if bleeding risk is acceptable 1
• P2Y12 inhibitors (like clopidogrel) should generally be stopped before CABG (clopidogrel ≥5 days before) and not routinely restarted immediately post-CABG 1

Timing of Anticoagulation

• Low Molecular Weight Heparin (LMWH) like tinzaparin should be discontinued 12-24 hours before CABG and replaced with unfractionated heparin per institutional practice 1
• Restarting LMWH immediately post-CABG while on continuous telemetry significantly increases bleeding risk 2, 3

Bleeding Risk Considerations

Evidence on Bleeding Risk

• Dual antiplatelet therapy (DAPT) with clopidogrel and aspirin significantly increases the risk of bleeding complications when administered early after CABG 2
• Studies show that clopidogrel administration within 5 days before CABG increases early mortality and morbidity, with highest risk when given within 48 hours of surgery 3
• The risk of mediastinal re-exploration is significantly higher (8.33% vs 1.25-1.59%) when dual antiplatelet therapy is continued until 24 hours before CABG 2

Monitoring Considerations

• Continuous telemetry (CTT) is typically used in the immediate post-CABG period to monitor for arrhythmias, particularly atrial fibrillation which occurs in approximately one-third of patients 2-3 days after CABG 1
• The presence of CTT suggests the patient is still in the early post-operative period where bleeding risk is highest 1

Special Circumstances

When DAPT May Be Considered

• DAPT with aspirin and clopidogrel may be considered in selected patients at greater risk of graft occlusion and low risk of bleeding, but not in the immediate post-operative period 1
• A meta-analysis showed that ticagrelor-based DAPT provided superior vein graft patency compared to aspirin alone, but with increased bleeding rates 1

Atrial Fibrillation After CABG

• For patients who develop atrial fibrillation after CABG, the impact of early oral anticoagulation initiation remains unclear 1
• Some studies show early OAC initiation was associated with lower risk of thromboembolic events, while others show no reduction but increased major bleeding risk 1

Recommended Approach

1. Start with aspirin 75-100 mg daily as soon as there is no concern about bleeding 1
2. Defer clopidogrel initiation until patient is stable and off continuous telemetry 2, 3
3. Avoid tinzaparin in the immediate post-CABG period while on telemetry 1, 2
4. Consider adding a proton pump inhibitor to reduce gastrointestinal bleeding risk if antithrombotic therapy is necessary 1