When should we restart Plavix (clopidogrel) post hemorrhagic stroke?

Restarting Clopidogrel After Hemorrhagic Stroke

For patients with hemorrhagic stroke, antiplatelet therapy such as clopidogrel (Plavix) should be discontinued during the acute period for at least 1-2 weeks after the hemorrhage, and can be considered for restart at 7-10 days after the original hemorrhage in patients with very high thromboembolism risk. 1

Initial Management After Hemorrhagic Stroke

• All antiplatelet agents, including clopidogrel, should be immediately discontinued in patients presenting with hemorrhagic stroke 1
• The anticoagulant effect should be reversed immediately with appropriate agents if the patient was on anticoagulants 1
• During the acute phase (first 1-2 weeks), antiplatelet therapy should be withheld to minimize the risk of hematoma expansion 1

Factors Influencing Decision to Restart Clopidogrel

Risk Assessment

• The decision to restart antithrombotic therapy depends on balancing the risk of:
  • Subsequent arterial or venous thromboembolism
  • Risk of recurrent hemorrhagic stroke
  • Overall neurological status of the patient 1

Timing Considerations

• For patients with very high thromboembolism risk, it may be reasonable to restart clopidogrel at 7-10 days after the original hemorrhage 1
• For most patients, waiting at least 1-2 weeks is recommended before considering restarting antiplatelet therapy 1
• A brain imaging study (CT or MRI) should be performed before restarting therapy to ensure the hemorrhage has stabilized 2

Patient-Specific Risk Stratification

Higher Risk of Recurrent Hemorrhage (Consider Delaying or Avoiding Restart)

• Patients with lobar intracerebral hemorrhage (ICH) or evidence of cerebral amyloid angiopathy 1
• Elderly patients with lobar ICH 1
• Patients with multiple microbleeds on MRI 1
• Patients with very poor overall neurological function 1

Higher Risk of Thromboembolism (Consider Earlier Restart)

• Patients with mechanical heart valves 1
• Patients with recent arterial stenting 3
• Patients with high CHADS2 score (≥4 points) for atrial fibrillation 1

Evidence for Antiplatelet Therapy After ICH

• The RESTART trial found that antiplatelet therapy appeared to be safe after intracerebral hemorrhage that occurred during antithrombotic therapy 4
• Antiplatelet therapy did not significantly increase the risk of recurrent ICH (8.2% with antiplatelet therapy vs 9.3% without) 4
• Major vascular events were numerically lower with antiplatelet therapy (26.8%) compared to avoiding antiplatelet therapy (32.5%) 4

Practical Recommendations

1. Discontinue clopidogrel immediately upon diagnosis of hemorrhagic stroke 1
2. Wait at least 1-2 weeks after the hemorrhage before considering restarting therapy 1
3. Obtain brain imaging before restarting to confirm hemorrhage stabilization 2
4. For patients with very high thromboembolism risk, consider restarting clopidogrel at 7-10 days after the original hemorrhage 1
5. For patients with lobar hemorrhage or suspected cerebral amyloid angiopathy, consider longer delay or alternative strategies 1
6. When restarting antiplatelet therapy, consider using a single agent rather than dual antiplatelet therapy to minimize bleeding risk 3, 5

Special Considerations

• For patients with hemorrhagic transformation of ischemic stroke (rather than primary ICH), antiplatelet therapy may be continued depending on the specific clinical scenario and underlying indication 1
• In patients with a comparatively lower risk of cerebral infarction and higher risk of amyloid angiopathy, an antiplatelet agent may be considered for prevention of ischemic stroke 1
• Consider consultation with specialists (stroke neurologist, cardiologist, hematologist) for complex cases 1