In a patient on dabigatran (Pradaxa) and clopidogrel (Plavix) who requires coronary artery bypass grafting and has a recent coronary stent, how should the anticoagulant and antiplatelet therapy be managed pre‑ and post‑operatively?

Management of Dabigatran and Clopidogrel in Patients Requiring CABG with Recent Stent

In patients on dabigatran (Pradaxa) and clopidogrel (Plavix) who require CABG and have a recent coronary stent, discontinue dabigatran 3-5 days before surgery (depending on renal function), stop clopidogrel 5 days preoperatively, maintain aspirin throughout the perioperative period if bleeding risk allows, and resume both agents as soon as hemostasis is achieved postoperatively. 1, 2

Pre-operative Management

Timing of Surgery

• Delay elective CABG for at least 1 month after stent placement, regardless of stent type (bare-metal or drug-eluting), if aspirin can be maintained perioperatively 1
• If the patient had an acute coronary syndrome or has high ischemic-risk features, consider delaying surgery for 6 months after stent implantation 1
• A multidisciplinary team (cardiologist, cardiac surgeon, anesthesiologist) must evaluate the patient before proceeding 1, 3

Discontinuation Protocol for Dabigatran

• Stop dabigatran 1-2 days before surgery if creatinine clearance (CrCl) ≥50 mL/min 2
• Stop dabigatran 3-5 days before surgery if CrCl <50 mL/min 2
• For major surgery like CABG where complete hemostasis is required, consider the longer discontinuation period 2
• The specific reversal agent idarucizumab is available for emergency situations when immediate reversal of dabigatran is needed 2

Discontinuation Protocol for Clopidogrel

• Stop clopidogrel 5 days before CABG to allow adequate platelet recovery 1, 4
• This 5-day window accounts for the irreversible platelet inhibition that lasts for the lifetime of the platelet (7-10 days) 4

Aspirin Management

• Continue aspirin throughout the perioperative period whenever the bleeding risk allows 1, 3
• Use low-dose aspirin (75-100 mg daily) 1
• Aspirin should only be discontinued if CABG involves very high bleeding risk and both antiplatelet agents must be stopped 1

Critical Pitfall to Avoid

• Never substitute antiplatelet therapy with heparin or low-molecular-weight heparin as bridging therapy, as these agents do not prevent stent thrombosis 1, 3, 5

Post-operative Management

Resumption of Antiplatelet Therapy

• Resume clopidogrel as soon as possible postoperatively, ideally within 24 hours once hemostasis is achieved 1
• Consider administering a loading dose of clopidogrel (300 mg) when restarting 1, 6
• Continue aspirin without interruption if it was maintained perioperatively 1

Resumption of Dabigatran

• Restart dabigatran as soon as medically appropriate after surgery when hemostasis is secure 2
• The decision to resume should balance the thrombotic risk (from atrial fibrillation or other indication) against ongoing bleeding risk 2

Duration of Dual/Triple Therapy

Triple Therapy Considerations

• Since this patient requires oral anticoagulation (dabigatran) plus dual antiplatelet therapy, they are on triple antithrombotic therapy 1
• Limit triple therapy duration to a maximum of 6 months or discontinue at hospital discharge, depending on ischemic versus bleeding risk 1
• Triple therapy increases bleeding risk 2-3 fold compared to oral anticoagulation alone 1

Transition Strategy After CABG

• After the immediate post-CABG period, transition from triple therapy to dual therapy (dabigatran plus clopidogrel) by discontinuing aspirin 1, 7
• Clopidogrel is the P2Y12 inhibitor of choice when combined with oral anticoagulation; ticagrelor and prasugrel are not recommended in this setting 1, 7
• Continue dual therapy (dabigatran plus clopidogrel) for 12 months after the acute coronary syndrome or stent placement 1, 7
• After 12 months, continue dabigatran monotherapy for stroke prevention in atrial fibrillation 7

Special Considerations for This Patient Population

Bleeding Risk Mitigation

• Use proton pump inhibitors to reduce gastrointestinal bleeding risk while on combination therapy 1
• Pantoprazole or rabeprazole are preferred over omeprazole or esomeprazole, which can reduce clopidogrel's antiplatelet activity 1, 4
• Monitor closely for signs of bleeding (hemoglobin drop, hematocrit decline, hypotension) 2

Evidence Supporting Dual Over Triple Therapy

• Recent evidence from the RE-DUAL PCI trial demonstrates that dabigatran 110 mg or 150 mg twice daily plus clopidogrel (dual therapy) reduces bleeding risk compared to warfarin triple therapy, with similar thromboembolic outcomes, even in patients with procedural or clinical complexity 8
• This finding supports early discontinuation of aspirin and continuation of dabigatran plus clopidogrel as the preferred long-term strategy 7, 8

Monitoring Post-operatively

• Assess for signs of stent thrombosis (chest pain, ST-segment changes, troponin elevation) 3, 6
• Monitor for bleeding complications (surgical site bleeding, gastrointestinal bleeding, intracranial hemorrhage) 2, 9
• Resume antiplatelet and anticoagulant therapy at the earliest safe opportunity to minimize thrombotic risk 1, 6