From the Guidelines
For a 45-year-old male with Factor V Leiden on Plavix (clopidogrel) for ischemic CVA requiring surgery, I recommend discontinuing Plavix 5-7 days before elective surgery to reduce bleeding risk, as supported by the most recent guidelines 1.
Perioperative Management
The patient's history of ischemic CVA and Factor V Leiden mutation increases the risk of thrombotic events, but the use of Plavix (clopidogrel) also increases the risk of bleeding during surgery.
- The 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery recommends discontinuing antiplatelet therapy, such as clopidogrel, 5-7 days before elective surgery to reduce bleeding risk 1.
- For procedures with low bleeding risk, discontinuation may be shortened to 3 days.
- No bridging anticoagulation is typically needed.
Restarting Anticoagulation
- The patient should restart Plavix 24-48 hours after surgery when hemostasis is adequate, with the exact timing depending on the bleeding risk of the procedure.
- During the perioperative period, maintain other preventive measures such as compression stockings and early mobilization.
Urgent Procedures
- For urgent procedures, consider platelet transfusion if surgery cannot be delayed.
- Discuss the specific timing with both the surgeon and cardiologist/neurologist to personalize the approach based on the patient's thrombotic versus bleeding risk profile. This approach balances thrombotic risk from Factor V Leiden and previous stroke against perioperative bleeding concerns, as recommended by the most recent guidelines 1.
From the FDA Drug Label
Discontinue 5 days prior to elective surgery that has a major risk of bleeding. ( 5.3)
The patient should discontinue clopidogrel (Plavix) 5 days prior to elective surgery to minimize the risk of bleeding, considering the major risk of bleeding associated with the surgery.
- Bleeding risk is a concern in patients on clopidogrel, especially those with a history of ischemic CVA and factor V Leiden.
- No specific recommendations are provided for patients with factor V Leiden, but caution is advised when discontinuing anticoagulation therapy. 2
From the Research
Preoperative Anticoagulation Recommendations
For a 45-year-old male with Factor V Leiden on Plavix for an ischemic CVA, the following points should be considered:
- The patient has a history of ischemic stroke and is taking Plavix, an antiplatelet agent, which increases the risk of bleeding [ 3 ].
- Factor V Leiden is a genetic disorder that increases the risk of thrombosis, and the patient may require anticoagulation therapy to prevent venous thromboembolic events [ 4 ].
- Low-molecular-weight heparin (LMWH) or heparinoids may be used for thromboprophylaxis in patients with acute ischemic stroke, but the risk of bleeding should be carefully considered [ 5 ].
- The American College of Chest Physicians recommends that patients with acute ischemic stroke receive thromboprophylaxis with LMWH or unfractionated heparin, unless contraindicated [ 6 ].
Anticoagulation Therapy Options
The following anticoagulation therapy options may be considered:
- LMWH: has a more predictable anticoagulant effect and lower risk of bleeding compared to unfractionated heparin [ 6 ].
- Unfractionated heparin: may be used for thromboprophylaxis in patients with acute ischemic stroke, but requires careful monitoring of activated partial thromboplastin time (aPTT) [ 6 ].
- Heparinoids: may be used as an alternative to LMWH or unfractionated heparin, but the evidence for their use in patients with acute ischemic stroke is limited [ 7 ].
Risks and Benefits
The risks and benefits of anticoagulation therapy should be carefully considered, including:
- Risk of bleeding: anticoagulation therapy increases the risk of bleeding, particularly in patients taking antiplatelet agents like Plavix [ 3 ].
- Risk of thrombosis: patients with Factor V Leiden are at increased risk of thrombosis, and anticoagulation therapy may be necessary to prevent venous thromboembolic events [ 4 ].