Duration of Plavix (Clopidogrel) After Heart Attack
Patients should receive clopidogrel 75 mg daily plus aspirin for a minimum of 12 months after a heart attack, regardless of whether they received a stent, medical therapy alone, or fibrinolytic therapy. 1, 2
Standard 12-Month Duration Applies to All Heart Attack Patients
The American College of Cardiology gives a Class I (strongest) recommendation for 12 months of dual antiplatelet therapy (DAPT) with clopidogrel 75 mg daily plus aspirin in all acute coronary syndrome patients, based on Level A evidence from the CURE trial. 1, 2
For patients who underwent percutaneous coronary intervention (PCI) with stent placement, clopidogrel 75 mg daily should continue for at least 12 months regardless of stent type (bare-metal or drug-eluting). 1
For patients managed with medical therapy alone (no stent), the CURE trial demonstrated a 2.1% absolute reduction in death, heart attack, and stroke with 12 months of clopidogrel plus aspirin compared to aspirin alone. 2, 3
For patients who received fibrinolytic (clot-busting) therapy, the CLARITY-TIMI 28 and COMMIT trials support 12 months of clopidogrel therapy, with the COMMIT trial showing a 9% relative risk reduction in death, reinfarction, or stroke. 2, 4
Aspirin Dose Matters for Safety
Use low-dose aspirin 81 mg daily (range 75-100 mg) when taking clopidogrel, as higher aspirin doses increase bleeding risk without improving efficacy. 2
The American College of Cardiology specifically warns against using aspirin doses above 100 mg daily with clopidogrel due to increased bleeding complications. 1
When to Consider Extending Beyond 12 Months
Patients may reasonably continue clopidogrel beyond 12 months if they have tolerated DAPT without bleeding complications, are not at high bleeding risk, and understand the benefits and risks. 1, 2
Extended DAPT reduces recurrent heart attacks by 1-3% absolute risk but increases major bleeding by approximately 1% absolute risk, based on the PEGASUS-TIMI 54 trial. 2
The American College of Cardiology gives a Class IIb recommendation (may be considered) for extending DAPT beyond 12 months in carefully selected patients. 1
When to Consider Shorter Duration (High Bleeding Risk)
Patients at high bleeding risk or who develop significant bleeding may discontinue clopidogrel at 6 months, though this is a weaker recommendation (Class IIb, Level C evidence). 1
The 2017 European Society of Cardiology guidelines suggest that for high bleeding risk patients with acute coronary syndrome, shortening DAPT to 6 months may be considered (Class IIb recommendation). 1
Stronger Alternatives to Clopidogrel
Ticagrelor or prasugrel may be preferred over clopidogrel for maintenance therapy in acute coronary syndrome patients based on the PLATO and TRITON-TIMI 38 trials. 1, 2
Ticagrelor 90 mg twice daily is reasonable to use in preference to clopidogrel for ACS patients (Class IIa recommendation). 1, 2
Prasugrel 10 mg daily is reasonable over clopidogrel in ACS patients who are not at high bleeding risk and have no history of stroke or transient ischemic attack. 1, 2
Critical Timing for Surgical Procedures
Clopidogrel must be discontinued at least 5 days before elective coronary artery bypass grafting (CABG) to reduce perioperative bleeding risk. 1
For urgent CABG, surgery may be performed less than 5 days after clopidogrel discontinuation if clinically necessary, but ideally not sooner than 24 hours. 1
Elective non-cardiac surgery should be delayed for 30 days after bare-metal stent placement and optimally 6 months after drug-eluting stent placement to avoid premature discontinuation of DAPT. 2
Common Pitfalls to Avoid
Never discontinue clopidogrel prematurely for elective procedures during the first 12 months after a heart attack, as this dramatically increases the risk of stent thrombosis and recurrent cardiovascular events. 1, 5
The hazard ratio for subacute stent thrombosis with premature DAPT discontinuation is 161, and for late stent thrombosis is 57. 5
Do not use clopidogrel in patients with MINOCA (myocardial infarction with non-obstructive coronary arteries) at intensified doses, as a trial showed possible harm with double-dose clopidogrel in this population (HR 3.57 for primary outcomes). 6