Should a 57-year-old female patient with a history of coronary artery disease (CAD) and significant lumen blocking, who was prescribed clopidogrel (Plavix) after an angiogram, continue taking her antiplatelet therapy?

Should This Patient Continue Clopidogrel for Her Coronary Artery Disease?

Yes, this 57-year-old woman with significant coronary artery disease and lumen-blocking lesions documented on angiogram should absolutely continue her clopidogrel 75 mg daily indefinitely. 1

Rationale for Continued Therapy

Established CAD with Significant Stenosis

• Patients with documented coronary atherosclerosis and flow-limiting stenoses require long-term antiplatelet therapy with either aspirin or clopidogrel to prevent recurrent ischemic events 2
• For patients with established peripheral arterial disease or history of recent myocardial infarction or stroke, clopidogrel is indicated to reduce the rate of MI and stroke 1
• The standard maintenance dose is 75 mg once daily without a loading dose for chronic stable CAD 1

Critical Importance of Continuation

• Discontinuation of clopidogrel increases the risk of cardiovascular events 1
• The FDA label explicitly warns that if clopidogrel must be temporarily discontinued (e.g., for surgery with major bleeding risk), it should be restarted as soon as possible 1
• When interruption is necessary, therapy should be stopped for five days prior to surgery and resumed as soon as hemostasis is achieved 1

Verification Points During Your Visit

Confirm Current Medication Status

• Verify she is taking clopidogrel 75 mg daily consistently 1
• Ask about any missed doses or self-discontinuation
• Assess for any bleeding complications that might have prompted discontinuation 1

Check for Contraindications

• Active pathological bleeding (peptic ulcer, intracranial hemorrhage) would contraindicate continued use 1
• History of hypersensitivity reactions to clopidogrel or other thienopyridines 1
• Recent thrombotic thrombocytopenic purpura (TTP) symptoms: unexplained thrombocytopenia, neurological findings, fever, renal dysfunction 1

Assess Drug Interactions

• Avoid concomitant omeprazole or esomeprazole as they significantly reduce clopidogrel's antiplatelet activity 1
• If proton pump inhibitor needed for GI protection, use pantoprazole or rabeprazole instead 2
• Review other medications that increase bleeding risk: anticoagulants, NSAIDs, other antiplatelet agents 1

Special Considerations for This Patient

If She Had Coronary Stenting

• If bare-metal stent was placed, minimum 1 month of clopidogrel is required, ideally up to 12 months 3
• If drug-eluting stent was placed, minimum 12 months of clopidogrel is mandatory 2, 4
• Never discontinue dual antiplatelet therapy abruptly in post-stent patients due to catastrophic stent thrombosis risk 5

If Medical Management Only (No Stenting)

• Continue clopidogrel indefinitely for secondary prevention in patients with documented coronary atherosclerosis 2
• Long-term treatment with antiplatelet therapy and other secondary prevention measures should be prescribed for patients with evidence of coronary atherosclerosis, even without flow-limiting stenoses 2

If Future Surgery Planned

• For elective procedures, stop clopidogrel 5 days before surgery only if bleeding risk outweighs ischemic benefit 2
• For urgent surgery in high-risk patients with severe CAD, consider proceeding without discontinuation if ischemic risk exceeds bleeding risk 6
• Resume clopidogrel within 24 hours post-operatively once hemostasis is achieved 7

Common Pitfalls to Avoid

• Do not discontinue clopidogrel without cardiology consultation, especially if coronary stents are present 7
• Do not assume aspirin alone is sufficient for patients with significant CAD who were specifically prescribed clopidogrel 8
• Do not prescribe omeprazole or esomeprazole for GI protection as they negate clopidogrel's effect 1
• Do not delay restarting clopidogrel after any necessary interruption, as cardiovascular event risk increases immediately 1