Should a patient who underwent Coronary Artery Bypass Grafting (CABG) 3 months ago discontinue aspirin and Plavix (clopidogrel) prior to undergoing dental filling and root canal procedures under local anesthesia?

From the Guidelines

For a patient who had coronary artery bypass grafting (CABG) 3 months ago and is now scheduled for a dental filling and root canal under local anesthesia, it is recommended to continue aspirin and not stop it, but the decision to stop or continue Plavix (clopidogrel) should be based on the current guidelines and patient's specific condition, as stated in the 2024 ESC guidelines for the management of chronic coronary syndromes 1. The patient should not stop aspirin before the dental procedure, as low-dose aspirin is recommended lifelong in patients undergoing CABG, according to the 2024 ESC guidelines 1.

• The risk of significant bleeding during routine dental procedures under local anesthesia is typically low and manageable with local hemostatic measures such as pressure, topical thrombin, or tranexamic acid mouthwash if needed.
• The dentist should be informed about the patient's cardiac history and current medications before the procedure.
• The potential cardiovascular risks of stopping antiplatelet therapy (stent thrombosis, myocardial infarction) far outweigh the risk of bleeding during most dental procedures.
• If there are specific concerns about excessive bleeding risk, the dental provider should consult with the patient's cardiologist to develop an individualized plan, but unilateral discontinuation of these medications should be avoided, considering the guidelines from the 2024 ESC guidelines for the management of chronic coronary syndromes 1. The decision to stop Plavix should be made based on the current guidelines, which recommend stopping other antithrombotic drugs at intervals related to their duration of action, with clopidogrel stopped ≥5 days before the procedure, if necessary, as stated in the 2024 ESC guidelines 1.
• However, considering the patient's recent CABG and the importance of antiplatelet therapy in maintaining graft patency, the decision to stop Plavix should be made with caution and in consultation with the patient's cardiologist.
• The 2024 ESC guidelines also mention that DAPT with a P2Y12 receptor inhibitor compared with aspirin monotherapy provides higher graft patency rates after CABG, but with increased rates of bleeding, as seen in a meta-analysis of four RCTs 1.

From the FDA Drug Label

Talk with your doctor about stopping your clopidogrel tablets before you have surgery. Your doctor may tell you to stop taking clopidogrel tablets at least 5 days before you have surgery to avoid excessive bleeding during surgery. Discontinue 5 days prior to elective surgery that has a major risk of bleeding.

The patient should discuss with their doctor about stopping clopidogrel (Plavix) before the dental procedure. The doctor may advise stopping clopidogrel at least 5 days before the procedure to avoid excessive bleeding.

• However, aspirin is not explicitly mentioned in the context of stopping before a dental procedure in the provided drug labels.
• It is crucial to consult the doctor for specific guidance on managing aspirin and clopidogrel therapy before the dental procedure, considering the patient's medical history and the nature of the procedure 2 2.

From the Research

Management of Antiplatelet Therapy in CABG Patients Undergoing Dental Procedures

• The decision to stop aspirin and Plavix (clopidogrel) in a CABG patient undergoing dental filling and root canal under local anesthesia should be made in consultation with the patient's cardiologist and dentist.
• Studies have shown that continuing antiplatelet therapy during dental procedures does not significantly increase the risk of bleeding 3, 4.
• In fact, a study found that single and multiple dental extractions in patients receiving acetylsalicylic acid or clopidogrel can be safely performed without discontinuation of the therapy with provided appropriate local haemostasis 3.
• Another study suggested that the use of dual antiplatelet therapy, such as aspirin and clopidogrel, may have significant protective effects in patients undergoing off-pump CABG, and that stopping these medications may put patients at risk of adverse thrombotic events 5.
• The American Heart Association recommends that patients with a history of CABG should continue their antiplatelet therapy, including aspirin and clopidogrel, unless there is a strong contraindication 6, 7.

Considerations for Dental Procedures

• Local anesthesia can be used safely in patients taking antiplatelet therapy, and local haemostasis with gelatine sponge and/or suturing can be used to control bleeding 3.
• The dentist and physician should work together to manage the patient's care, taking into account the patient's medical and dental history 4.
• The risk of bleeding during dental procedures can be minimized with proper planning and management, and the benefits of continuing antiplatelet therapy often outweigh the risks 5, 3.