When to discontinue Plavix (clopidogrel)?

When to Discontinue Plavix (Clopidogrel)

The decision to discontinue clopidogrel depends primarily on the indication for therapy and the bleeding risk of any planned procedure, with stent type and timing being the most critical factors determining thrombotic risk. 1

Discontinuation Based on Stent Type and Timing

Drug-Eluting Stents (DES)

• Continue clopidogrel for at least 12 months after DES placement unless the bleeding risk clearly outweighs the benefit 2, 1
• Elective procedures with significant bleeding risk should be deferred until 12 months have passed after DES implantation 2
• Premature discontinuation is one of the strongest predictors of catastrophic stent thrombosis, which can result in death or myocardial infarction 2

Bare Metal Stents (BMS)

• Continue clopidogrel for a minimum of 1 month after BMS placement, ideally up to 12 months 2, 1
• Elective procedures should be deferred for at least 1 month after BMS implantation 2

After Completing Recommended Duration

• Once the minimum duration is completed (12 months for DES, 1 month for BMS), clopidogrel can be safely discontinued in patients with low thrombotic risk 1
• Consider continuation beyond 12 months in higher-risk patients, including those with previous stent thrombosis, left main stenting, multivessel stenting, or stenting of the only remaining coronary artery 2

Discontinuation for Surgical Procedures

Elective Surgery Timing

• Discontinue clopidogrel at least 5 days before elective surgery to allow for dissipation of antiplatelet effects 2, 3
• This 5-day window is based on the platelet lifespan and the irreversible nature of clopidogrel's antiplatelet effect 3, 4

Coronary Artery Bypass Grafting (CABG)

• For elective CABG, discontinue clopidogrel at least 5 days before surgery 2
• For urgent CABG, discontinue clopidogrel at least 24 hours before surgery to reduce major bleeding, though this increases bleeding risk compared to the 5-day window 2

High-Risk Bleeding Procedures

• For procedures with significant bleeding risk (neurosurgery, spinal surgery, posterior eye chamber surgery), discontinue clopidogrel 5-7 days before the procedure 1, 4
• For high-risk endoscopic procedures (esophageal dilation, EMR, ESD, variceal therapy), discontinue clopidogrel 7 days before in low thrombotic risk patients 5

Low-Risk Procedures

• Diagnostic endoscopy without intervention does not require clopidogrel discontinuation 5
• Most surgical procedures can be performed while continuing low-dose aspirin 4

Critical Management Principles

When Clopidogrel Must Be Stopped

• Always continue aspirin if at all possible when clopidogrel must be discontinued, especially in patients with prior stent placement 2, 5
• Resume clopidogrel as soon as possible after the procedure, typically within 24-48 hours once hemostasis is achieved 2, 1, 5
• The FDA label explicitly states: "When possible, interrupt therapy with clopidogrel for five days prior to such surgery. Resume clopidogrel as soon as hemostasis is achieved" 3

High Thrombotic Risk Patients

High thrombotic risk includes 1:

• DES within 12 months of placement
• BMS within 1 month of placement
• Prosthetic metal heart valve in mitral position
• Atrial fibrillation with mitral stenosis
• Less than 3 months after venous thromboembolism

For high thrombotic risk patients requiring surgery, consult with cardiology before discontinuing clopidogrel to discuss the risk-benefit ratio and optimal management strategy 2, 1, 5

Common Pitfalls to Avoid

• Never bridge with heparin or low-molecular-weight heparin when stopping clopidogrel - there is no evidence that anticoagulants reduce the risk of stent thrombosis after discontinuation of oral antiplatelet agents 2, 5
• Do not stop aspirin when discontinuing clopidogrel in patients on dual antiplatelet therapy 2, 5
• Do not discontinue clopidogrel without consulting the patient's cardiologist if the indication or timing is unclear 2
• Recognize that the median time to stent thrombosis after stopping both aspirin and clopidogrel is only 7 days 2

Special Considerations

Non-Stent Indications

• For patients with recent MI, recent stroke, or established peripheral arterial disease (without recent stent), clopidogrel is typically continued long-term at 75 mg daily 3
• Discontinuation in these patients should be based on individual bleeding risk versus ongoing thrombotic risk

Bleeding Complications

• If significant bleeding occurs (epistaxis, gastrointestinal bleeding), the decision to discontinue must weigh the severity of bleeding against thrombotic risk 6
• Epistaxis leads to premature clopidogrel discontinuation in approximately 20% of patients, increasing stent thrombosis risk 6
• Discontinuation of clopidogrel increases the risk of cardiovascular events and should only occur when absolutely necessary 3