Should Plavix (clopidogrel) be continued perioperatively in a patient with a history of cardiac stent placement and pulmonary embolism (PE) undergoing an orthopedic procedure?

From the Guidelines

For a patient with a cardiac stent placed 15 years ago who is on Plavix (clopidogrel) and has a history of pulmonary embolism (PE) 12 months ago undergoing an orthopedic procedure, the most appropriate management of perioperative antiplatelet therapy is to discontinue Plavix 5-7 days before the procedure and use bridging anticoagulation therapy. The patient's stent was placed more than 15 years ago, which is well beyond the period of highest thrombotic risk, as noted in the guidelines 1. However, the recent PE history requires anticoagulation management, and bridging therapy with either low molecular weight heparin (such as enoxaparin 1 mg/kg twice daily) or unfractionated heparin should be used, stopping 24 hours before surgery and resuming 24-48 hours after surgery when hemostasis is adequate 1. Plavix can be restarted 24-48 hours postoperatively when the bleeding risk has decreased. This approach balances the risk of stent thrombosis (low after 15 years) against the risk of surgical bleeding while providing protection against recurrent venous thromboembolism. The orthopedic surgeon and a cardiologist should ideally be consulted to develop a personalized perioperative plan based on the specific orthopedic procedure and the patient's complete cardiovascular risk profile, as recommended by the guidelines 1. Key considerations include:

• The risk of stent thrombosis is low after 15 years, but anticoagulation management is necessary for the recent PE history.
• Bridging anticoagulation therapy should be used to minimize the risk of recurrent venous thromboembolism.
• The patient's cardiovascular risk profile and the specific orthopedic procedure should be taken into account when developing a personalized perioperative plan. It is essential to weigh the benefits and risks of continuing or discontinuing antiplatelet therapy in the perioperative period, considering the patient's individual risk factors and the type of surgery being performed, as emphasized in the guidelines 1.

From the FDA Drug Label

5.3 Discontinuation of Clopidogrel Discontinuation of clopidogrel increases the risk of cardiovascular events. If clopidogrel must be temporarily discontinued (e.g., to treat bleeding or for surgery with a major risk of bleeding), restart it as soon as possible. When possible, interrupt therapy with clopidogrel for five days prior to such surgery. Resume clopidogrel as soon as hemostasis is achieved.

The patient should not stop taking clopidogrel (Plavix) without consulting their doctor, as discontinuation increases the risk of cardiovascular events.

• If the medication must be temporarily discontinued for surgery, it should be restarted as soon as possible.
• Ideally, therapy with clopidogrel should be interrupted for five days prior to surgery with a major risk of bleeding.
• The medication should be resumed as soon as hemostasis is achieved 2.

From the Research

Perioperative Management of Patients on Clopidogrel

The patient in question has a history of cardiac stent placement 15 years ago and is currently on Plavix (clopidogrel), with a recent pulmonary embolism (PE) 12 months ago. The patient is now undergoing an orthopedic procedure, raising concerns about the management of clopidogrel perioperatively.

• The risk of bleeding versus the risk of cardiovascular events must be balanced when deciding whether to continue or discontinue clopidogrel perioperatively 3, 4, 5, 6.
• Studies suggest that, in selected patients, some surgical procedures can be performed safely while the patient is on clopidogrel, but this is associated with higher rates of postoperative transfusion 3.
• For patients with a history of drug-eluting stent placement, the risk of stent thrombosis is a significant concern if clopidogrel is discontinued 4, 7.
• The use of a bridging agent, such as eptifibatide, may minimize the risk of cardiovascular events in higher-risk patients 5.
• Current guidelines suggest that, except in low-risk settings, antiplatelet drugs should not be withdrawn 5-10 days prior to surgical procedures, and most surgical procedures can be performed while the patient is on low-dose aspirin treatment 6.
• For elective procedures, surgery should be postponed until the end of the indication for clopidogrel, and after the operation, clopidogrel should be resumed within 12-24 hours 6.

Considerations for Orthopedic Procedures

• Orthopedic surgeons must balance the risks of ceasing clopidogrel versus the risk of increased bleeding that dual antiplatelet therapy generates 4.
• Little good quality evidence exists regarding the risks of perioperative clopidogrel for orthopedic surgery, but available evidence suggests that efforts should be made to continue clopidogrel therapy through the perioperative period, taking precautions to minimize bleeding 4.
• Patients on clopidogrel who sustain a fall or other general trauma need to be carefully assessed because of the possibility of occult bleeding, such as into the retroperitoneal space 4.

Recommendations

• A team approach should be taken to assess the individual risks for all patients and consider continuation of clopidogrel therapy perioperatively where possible 4.
• The decision to continue or discontinue clopidogrel perioperatively should be made on a case-by-case basis, taking into account the patient's individual risk factors and the type of surgical procedure being performed 3, 4, 5, 6.