Does Plavix (clopidogrel) need to be discontinued prior to percutaneous coronary intervention (PCI)?

No, Plavix (Clopidogrel) Should NOT Be Discontinued Prior to PCI

Clopidogrel should be continued and, if not already on board, a loading dose should be administered before PCI—discontinuation is contraindicated and increases the risk of catastrophic thrombotic events. 1

Loading Dose Strategy for PCI

For Patients NOT Already on Clopidogrel

• Administer a 300-600 mg loading dose of clopidogrel as early as possible before or at the time of PCI. 1
• The 300 mg dose given at least 6 hours before the procedure has the strongest evidence for efficacy. 1, 2
• A 600 mg loading dose achieves faster platelet inhibition and may be preferred when the procedure is planned within less than 6 hours, though the evidence is less established than for 300 mg. 1
• In the CREDO trial, patients who received clopidogrel at least 6 hours before PCI experienced a 38.6% relative risk reduction in adverse events, while those treated less than 6 hours before showed no benefit. 2

For Patients Already on Clopidogrel

• Continue the daily 75 mg maintenance dose without interruption through the PCI procedure. 1
• No additional loading dose is required if the patient has been on adequate maintenance therapy. 1

Post-PCI Continuation Requirements

Duration Based on Stent Type

For bare-metal stents (BMS):

• Minimum 1 month of clopidogrel 75 mg daily (or minimum 2 weeks if bleeding risk is very high). 1
• Ideally continue up to 12 months. 1

For drug-eluting stents (DES):

• Minimum 3 months for sirolimus-eluting stents and 6 months for paclitaxel-eluting stents. 1
• At least 12 months is recommended for all DES, particularly in ACS patients. 1

For acute coronary syndromes (ACS):

• Clopidogrel must be continued for at least 12 months regardless of stent type. 1

Critical Warnings About Discontinuation

The Catastrophic Risk of Premature Cessation

• Abrupt discontinuation of clopidogrel is the leading cause of stent thrombosis with potentially fatal consequences. 3
• The American Heart Association emphasizes that patients with coronary stents should never discontinue clopidogrel, as abrupt cessation dramatically increases the risk of stent thrombosis, myocardial infarction, and death. 3
• The highest thrombotic risk period is within 30 days of stent placement, with an ongoing risk of 0.2-0.6% per year thereafter. 3

When Surgery Is Required

For elective non-cardiac surgery:

• Surgery should ideally be postponed beyond 12 months after DES implantation. 3
• If surgery cannot be delayed, aspirin 75-100 mg daily should be continued throughout the perioperative period. 3
• Contact the patient's cardiologist before making any changes to antiplatelet therapy. 3

For urgent CABG:

• Clopidogrel should be discontinued for at least 24 hours to reduce major bleeding. 1
• For elective CABG, discontinue clopidogrel at least 5 days before surgery. 1

Combination with Aspirin

• Aspirin should be administered concurrently with clopidogrel before, during, and after PCI. 1
• For patients not already on aspirin: give 300-325 mg at least 2 hours (preferably 24 hours) before PCI. 1
• For patients already on aspirin: continue the current regimen. 1
• After PCI, use aspirin 81 mg daily indefinitely in preference to higher maintenance doses. 1

Common Pitfalls to Avoid

The Elective PCI Pretreatment Controversy

• While one trial (PRAGUE-8) showed that 600 mg clopidogrel given more than 6 hours before elective PCI increased minor bleeding without significant reduction in periprocedural MI, this applies only to stable angina patients undergoing elective procedures. 4
• This does NOT apply to ACS patients or those already on clopidogrel—these patients must continue therapy without interruption. 1
• For truly elective PCI in stable patients, clopidogrel can be safely administered in the catheterization laboratory between angiography and PCI. 4

Alternative P2Y12 Inhibitors

• Prasugrel (60 mg loading dose) or ticagrelor (180 mg loading dose) are reasonable alternatives to clopidogrel at the time of PCI. 1
• Prasugrel is contraindicated in patients with prior stroke or TIA. 1
• It is reasonable to choose prasugrel over clopidogrel for ACS patients treated with an early invasive strategy. 1