I have a drug-eluting stent (DES) in my left anterior descending (LAD) artery and am taking Plavix (clopidogrel) daily, should I stop Plavix for 5 days before a stellate ganglion lidocaine injection?

Do Not Stop Plavix for 5 Days Before Stellate Ganglion Block

You should NOT discontinue Plavix for 5 days before a stellate ganglion lidocaine injection, as this is a low-risk procedure that does not require interruption of antiplatelet therapy, and stopping Plavix places you at unacceptable risk of stent thrombosis. 1, 2

Why This Recommendation is Critical

Your Stent Thrombosis Risk is Extremely High

• Discontinuing antiplatelet therapy is associated with a hazard ratio of 161 for death and myocardial infarction in patients with coronary stents 1
• Stent thrombosis carries approximately 40% risk of death or myocardial infarction if it occurs 1
• The risk of stent thrombosis increases significantly after just 5 days without antiplatelet therapy 1
• Your LAD stent location makes any thrombotic event potentially catastrophic, as this supplies the anterior wall of your left ventricle 1

Stellate Ganglion Block Does Not Require Plavix Interruption

• Stellate ganglion blocks are superficial, compressible procedures with minimal bleeding risk that do not fall into the category requiring antiplatelet interruption 2
• Guidelines recommend continuing antiplatelet therapy for procedures except those in closed spaces (intracranial, posterior eye chamber) or those with massive bleeding and difficult hemostasis 2
• A stellate ganglion injection is neither of these high-risk scenarios 2

What the Evidence Shows About Stopping Antiplatelet Therapy

When Interruption is Actually Indicated

The 5-7 day discontinuation period for Plavix applies specifically to: 1

• Coronary artery bypass grafting (CABG) - major cardiac surgery with cardiopulmonary bypass 1
• Intracranial neurosurgery - closed space with no compression possible 2
• Posterior eye chamber surgery - closed space procedures 2
• Major abdominal or thoracic surgery with anticipated massive blood loss 2

The Risk-Benefit Calculation

• The risk of cardiovascular events from stopping antiplatelet agents preoperatively is higher than the risk of surgical bleeding when continuing these drugs for most procedures 2
• Surgical hemorrhage risk increases approximately 20% with single antiplatelet therapy like Plavix alone 2
• However, premature discontinuation of antiplatelet therapy increases postoperative myocardial infarction and death risk 5- to 10-fold in stented patients 2

What You Should Do

Immediate Action Steps

1. Contact your interventional cardiologist who placed your stent to discuss this procedure and obtain their recommendation 1
2. Request a multidisciplinary discussion between your cardiologist and the provider performing the stellate ganglion block 1
3. Continue your Plavix without interruption unless your cardiologist specifically advises otherwise after reviewing your case 1, 2

Questions to Ask Your Cardiologist

• What type of drug-eluting stent do you have (this affects thrombosis risk)? 1
• How long ago was your stent placed (the date matters significantly)? 1
• Are there any other high-risk features of your stent (long stent, bifurcation location, multiple stents)? 3
• Do you have other risk factors for stent thrombosis (diabetes, reduced ejection fraction)? 3

Alternative Management Strategy

If the provider performing the stellate ganglion block refuses to proceed on Plavix: 1, 2

• Postpone the elective procedure until you complete at least 12 months of Plavix therapy after DES placement 1, 3
• Consider whether the stellate ganglion block is truly necessary or if alternative pain management exists 2
• If the procedure cannot be postponed and must be done, continue aspirin at minimum and discuss bridging therapy with IV glycoprotein IIb/IIIa inhibitors with your cardiologist 1, 4

Critical Pitfalls to Avoid

Never Do These Things

• Never stop both aspirin and Plavix simultaneously - this dramatically increases stent thrombosis risk 5
• Never substitute heparin or low-molecular-weight heparin for Plavix - anticoagulants do not protect against stent thrombosis and increase bleeding without providing platelet inhibition 5
• Never allow a non-cardiologist to make decisions about stopping antiplatelet therapy in patients with coronary stents without cardiology consultation 1, 6

Common Misconceptions

• Some healthcare providers incorrectly apply the "5-7 day rule" to ALL procedures, when it specifically applies only to major surgery 1, 2
• The provider requesting Plavix discontinuation may not understand the catastrophic consequences of stent thrombosis in your specific situation 6
• 57% of patients receive antiplatelet instructions from surgeons without cardiology input, leading to inappropriate recommendations 6

If You Must Proceed Despite These Concerns

Should your cardiologist agree (unlikely) that Plavix interruption is acceptable: 1

• Stop Plavix for the minimum possible time (potentially 3 days for minor procedures, not 5) 1
• Continue aspirin throughout the entire perioperative period 1, 2
• Resume Plavix immediately after the procedure, ideally within 24 hours 1, 3
• Consider bridging with IV tirofiban or eptifibatide if you are at very high thrombosis risk 1, 4

The bottom line: A stellate ganglion block is a superficial injection that should not require stopping Plavix. The thrombosis risk from stopping your antiplatelet therapy far exceeds any bleeding risk from this procedure. 1, 2