Do you continue Plavix (clopidogrel) and ASA (aspirin) before carotid endarterectomy?

Antiplatelet Management Before Carotid Endarterectomy

Continue aspirin (81-325 mg daily) before and through carotid endarterectomy, but stop clopidogrel 5 days before surgery unless the patient is recently symptomatic (within 2 weeks), in which case dual antiplatelet therapy should be continued perioperatively. 1

Standard Perioperative Antiplatelet Protocol

Aspirin Management

• Aspirin must be continued throughout the perioperative period without interruption 1
• Low-dose aspirin (81-325 mg daily) is the recommended range, with doses of 81-325 mg demonstrating superior outcomes compared to higher doses 1, 2
• The ACE trial definitively showed that patients on low-dose aspirin (81 or 325 mg) had significantly lower combined rates of stroke, myocardial infarction, and death (5.4% vs 7.0% at 30 days, p=0.07; 6.2% vs 8.4% at 3 months, p=0.03) compared to high-dose aspirin (650 or 1300 mg) 2
• Perioperative aspirin reduces overall complications (5.2% vs 17.6%, p<0.001), myocardial events (0.7% vs 4.4%, p=0.012), and stroke (1.5% vs 5.5%, p=0.036) without increasing bleeding complications requiring revision 3

Clopidogrel Management: The Critical Decision Point

For asymptomatic or remote symptomatic patients (>2 weeks from event):

• Stop clopidogrel 5 days before surgery 4
• This allows platelet function to recover sufficiently to minimize bleeding risk while maintaining aspirin for cardiovascular protection 1

For recently symptomatic patients (within 2 weeks of TIA or stroke):

• Continue dual antiplatelet therapy (aspirin plus clopidogrel) through surgery 5
• Early intervention within 2 weeks of the index event is reasonable, and dual antiplatelet therapy reduces recurrent cerebral events before CEA and significantly reduces stroke from early postoperative carotid thrombosis 1, 5
• Emerging evidence shows dual antiplatelet therapy in recently symptomatic patients is not associated with significant bleeding complications when post-CEA hypertension is aggressively treated 5

Evidence Quality and Nuances

The Bleeding Risk Controversy

There is conflicting evidence regarding dual antiplatelet therapy and bleeding:

• One retrospective study found clopidogrel/aspirin therapy was independently associated with a five-fold increased risk of postoperative bleeding (OR=5.1,95% CI: 1.8-14.2, p<0.002) 6
• However, more recent evidence suggests that when post-CEA hypertension is aggressively managed, dual antiplatelet therapy does not significantly increase bleeding complications 5
• The key differentiator is timing of symptoms and aggressive blood pressure management postoperatively 5

Critical Pitfall: Heparin-Aspirin Interaction

• Administration of unfractionated heparin during CEA temporarily reverses aspirin's antiplatelet effect, with platelet aggregation increasing more than 10-fold within 3 minutes of heparin administration (from 3.9% to 45.1%, p<0.0001) 7
• This phenomenon persists into the early postoperative period but resolves by 24 hours 7
• This is why continuing aspirin perioperatively is essential—to maintain some baseline antiplatelet effect despite this temporary reversal 7

Postoperative Management

Long-term Antiplatelet Therapy

• After the first month post-CEA, continue aspirin (75-325 mg daily), clopidogrel (75 mg daily), or aspirin plus extended-release dipyridamole for long-term prophylaxis against ischemic cardiovascular events 1
• Single antiplatelet therapy is generally preferred over dual therapy for long-term management due to bleeding risk considerations 8

Blood Pressure Management

• Aggressively treat post-CEA hypertension, especially in recently symptomatic patients undergoing surgery within 7-14 days of symptom onset 5
• Untreated post-CEA hypertension is associated with high rates of intracerebral hemorrhage, hyperperfusion syndrome, and major cardiac events 5
• This is particularly critical when dual antiplatelet therapy is continued perioperatively 5

Practical Algorithm

1. Assess symptom timing:

   • If asymptomatic or >2 weeks from last event: Stop clopidogrel 5 days before CEA, continue aspirin 1, 4
   • If <2 weeks from TIA/stroke: Continue both aspirin and clopidogrel through surgery 1, 5

2. Optimize aspirin dosing:

   • Use 81-325 mg daily (lower doses preferred) 1, 2
   • Never use doses >325 mg 2

3. Plan for postoperative hypertension management:

   • Have written protocols ready for prompt treatment 5
   • Monitor especially closely if dual antiplatelet therapy was continued 5

4. Resume or adjust therapy:

   • If clopidogrel was stopped, restart as soon as hemostasis is achieved 4
   • Transition to long-term single antiplatelet therapy after 1 month unless specific indications exist for dual therapy 1, 8