Is it okay to hold Plavix (clopidogrel) less than 3 months after catheterization?

Holding Plavix Less Than 3 Months After Catheterization

No, you should not hold Plavix (clopidogrel) less than 3 months after catheterization if a stent was placed—premature discontinuation dramatically increases the risk of stent thrombosis, myocardial infarction, and death, with a case-fatality rate of approximately 50%. 1, 2, 3

Critical Context: Was a Stent Placed?

The answer depends entirely on whether a stent was implanted during the catheterization:

If a Stent Was Placed (PCI Performed)

Do not discontinue clopidogrel under any circumstances without cardiology consultation. 2, 3

• Minimum duration of dual antiplatelet therapy (DAPT):

  • Bare-metal stent (BMS): Continue clopidogrel for at least 1 month, ideally up to 12 months 1
  • Drug-eluting stent (DES): Continue clopidogrel for at least 3-6 months, ideally 12 months 1
  • For acute coronary syndrome (ACS) patients with any stent: Continue for 12 months minimum 1, 4

• Early discontinuation of clopidogrel within the first 6 months after DES placement is a major predictor of stent thrombosis (hazard ratio = 13.74; 95% CI, 4.04-46.68; P < 0.001). 5

• The highest thrombotic risk period is within 30 days of stent placement, with ongoing risk of 0.2-0.6% per year thereafter. 2

If Only Diagnostic Catheterization (No Stent)

If the catheterization was purely diagnostic without any intervention:

• Clopidogrel can be held if there is no other indication for it (e.g., recent ACS, prior stent, peripheral arterial disease) 3
• However, if the patient has chronic coronary syndrome with prior MI or remote PCI, clopidogrel 75 mg daily should be continued lifelong as an alternative to aspirin 1

Management for Urgent/Elective Surgery

If you are considering holding clopidogrel for a surgical procedure:

Timing Recommendations

• Elective surgery should be deferred for 6 weeks after BMS placement and 6 months after DES placement. 3
• Ideally, postpone all elective procedures for 12 months after DES implantation. 1, 2

If Surgery Cannot Be Deferred

• Continue aspirin 75-100 mg daily throughout the perioperative period. 2, 3
• Minimize the duration of clopidogrel interruption—hold for only 5 days (preferably 7 days maximum) before surgery. 3, 6
• Resume clopidogrel as soon as hemostasis is achieved, typically within 12-24 hours post-procedure. 3, 6
• Contact the patient's cardiologist before making any changes to antiplatelet therapy. 2

High-Risk Scenarios Where Clopidogrel Should NOT Be Stopped

• Complex left main stem stenting 1
• Two-stent bifurcation procedures 1
• Suboptimal stenting result 1
• Prior stent thrombosis 1
• Recent acute coronary syndrome (within 12 months) 1, 4

Common Pitfalls to Avoid

• Abrupt discontinuation of clopidogrel is the leading cause of stent thrombosis with potentially fatal consequences. 2
• Stent thrombosis presents as STEMI in the majority of cases, with mortality rates of 20-45%. 1
• Replacing clopidogrel with heparin or low-molecular-weight heparin does NOT provide protection against stent thrombosis. 6
• Do not assume that because the patient feels well, it is safe to stop clopidogrel—late stent thrombosis can occur months or years after stent placement, particularly with DES. 1, 5

Special Considerations for Chronic Coronary Syndrome

For patients with stable coronary disease after the initial DAPT period:

• After completing the recommended DAPT duration, clopidogrel 75 mg daily can be continued as monotherapy (instead of aspirin) as a safe and effective alternative 1
• In patients at enhanced ischemic risk without high bleeding risk, adding a second antithrombotic agent to aspirin for extended long-term secondary prevention should be considered 1