Should I start a patient with greater than 70% carotid artery stenosis on Plavix (clopidogrel) while awaiting vascular services consult?

Management of Patients with >70% Carotid Artery Stenosis Awaiting Vascular Consult

Yes, you should start a patient with greater than 70% carotid artery stenosis on Plavix (clopidogrel) while awaiting vascular services consult. This is particularly important for patients with symptomatic carotid stenosis to reduce the risk of stroke during the waiting period.

Antiplatelet Therapy Recommendations

• For patients with symptomatic carotid stenosis (recent stroke or TIA within 6 months), antiplatelet therapy with aspirin alone (75-325 mg daily), clopidogrel alone (75 mg daily), or the combination of aspirin plus extended-release dipyridamole is recommended 1
• For asymptomatic patients with >70% carotid stenosis, antiplatelet therapy with aspirin (75-325 mg daily) is recommended to prevent myocardial infarction and other ischemic events 1
• In patients with recent symptoms (stroke or TIA), dual antiplatelet therapy with aspirin and clopidogrel for at least 21 days may provide additional benefit if carotid endarterectomy is delayed 2

Management Based on Symptom Status

For Symptomatic Patients (with recent stroke/TIA):

• Initiate antiplatelet therapy immediately - clopidogrel 75 mg daily is an appropriate choice 1
• These patients should undergo carotid revascularization (CEA or CAS) as soon as possible, ideally within 2 weeks of the index event 1
• The benefit of early intervention is substantial - CEA reduces the risk of recurrent stroke in patients with symptomatic stenosis >70% 1

For Asymptomatic Patients:

• Start antiplatelet therapy (clopidogrel 75 mg daily is appropriate) 1, 3
• Medical therapy should be optimized while awaiting vascular consultation 1
• The decision for revascularization should be guided by assessment of comorbidities, life expectancy, and individual risk factors 1

Timing Considerations

• For symptomatic patients, revascularization within 2 weeks of the index event is reasonable rather than delaying surgery 1
• Starting clopidogrel while awaiting vascular consultation helps bridge this waiting period and reduces stroke risk 1
• The benefit of clopidogrel begins within hours but may take several days to reach full effect if no loading dose is used 4

Important Precautions and Monitoring

• Document neurological examination findings before starting clopidogrel 1
• Monitor for bleeding complications, as P2Y12 inhibitors like clopidogrel increase bleeding risk 4
• Be aware that some patients may have reduced response to clopidogrel due to CYP2C19 genetic variants 4
• If surgical intervention is planned within 5 days, consider the increased risk of perioperative bleeding with clopidogrel 4

Special Considerations

• In older patients (>70 years), carotid endarterectomy (CEA) is generally preferred over carotid artery stenting (CAS) when revascularization is indicated 1, 5
• For patients with unfavorable neck anatomy for surgery, CAS may be more appropriate 1, 5
• If CAS is anticipated, dual antiplatelet therapy with aspirin and clopidogrel will be required before and for a minimum of 30 days after the procedure 1

Starting clopidogrel while awaiting vascular consultation is a prudent approach to reduce stroke risk in patients with significant carotid stenosis, particularly those who are symptomatic. This therapy should be continued until definitive management decisions are made by the vascular team.