From the Guidelines
In patients undergoing percutaneous coronary intervention (PCI), the administration of clopidogrel (Plavix) is typically continued, rather than held, to maintain antiplatelet therapy.
Key Points
- The recommended dose of clopidogrel is 75 mg orally per day, and it is generally recommended to continue this dose without interruption, including on the day of PCI, to minimize the risk of thrombotic complications 1.
- A loading dose of 600 mg may be administered at least 2 hours before PCI if the patient has not been pre-treated with clopidogrel 1.
- The necessity for giving a loading dose of clopidogrel before PCI is driven by the pharmacokinetics of clopidogrel, for which a period of several hours is required to achieve desired levels of platelet inhibition 1.
Considerations
- Patients who have a reduced-function CYP2C19 allele have significantly lower levels of the active metabolite of clopidogrel, diminished platelet inhibition, and a higher rate of major adverse cardiac events (MACE), including stent thrombosis 1.
- In STEMI patients taking clopidogrel for whom CABG is planned and can be delayed, it is reasonable to discontinue the clopidogrel to allow for dissipation of the antiplatelet effect, unless the urgency for revascularization and/or the net benefit of clopidogrel outweighs the potential risks of excess bleeding 1.
- The period of withdrawal should be at least 5 days in patients receiving clopidogrel 1.
- For post-PCI patients receiving a drug-eluting stent (DES), a daily maintenance dose should be given for at least 12 months unless the risk of bleeding outweighs the anticipated net benefit afforded by a thienopyridine 1.
From the Research
Holding Plavix (Clopidogrel) Before Percutaneous Coronary Intervention (PCI)
- The decision to hold Plavix (clopidogrel) before Percutaneous Coronary Intervention (PCI) depends on various factors, including the patient's condition and the timing of the procedure 2, 3.
- Studies have shown that administering a 600-mg loading dose of clopidogrel less than 2 hours before PCI can be effective in reducing the incidence of periprocedural myocardial infarctions 2.
- However, other studies have found that delaying PCI for 2 hours after clopidogrel loading does not necessarily confer any benefit compared to ad hoc PCI 4.
- The optimal timing of clopidogrel loading before PCI is still a topic of debate, with some studies suggesting that a higher loading dose (600 mg) may be more effective than a lower dose (300 mg) in inhibiting platelet aggregation 5.
- The American College of Cardiology and American Heart Association guidelines recommend pretreatment with a loading dose of clopidogrel before PCI to reduce the incidence of periprocedural myocardial infarctions 2, 3.
- The choice of whether to hold Plavix before PCI should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history 6, 4.
Key Findings
- A 600-mg loading dose of clopidogrel administered less than 2 hours before PCI can be effective in reducing periprocedural myocardial infarctions 2.
- Delaying PCI for 2 hours after clopidogrel loading does not necessarily confer any benefit compared to ad hoc PCI 4.
- A higher loading dose (600 mg) may be more effective than a lower dose (300 mg) in inhibiting platelet aggregation 5.
- The optimal timing of clopidogrel loading before PCI is still a topic of debate 2, 3, 6, 4.