What is the recommended duration to discontinue Plavix (clopidogrel) preoperatively for knee arthroscopy in a patient with a history of Factor V Leiden and ischemic stroke?

From the Guidelines

For a patient with a history of Factor V Leiden and previous ischemic stroke who is on Plavix (clopidogrel) and scheduled for knee arthroscopy, it is recommended to stop Plavix for at least 5 days before surgery. This recommendation is based on the guidelines for patients undergoing elective coronary artery bypass graft (CABG) surgery, which suggest discontinuing clopidogrel for at least 5 days before surgery to limit blood transfusions 1. Although the patient is undergoing knee arthroscopy, which may have a different bleeding risk profile compared to CABG, the principle of balancing thrombotic and bleeding risks remains relevant.

Considering the patient's history of ischemic stroke and Factor V Leiden, which increases the risk of thrombosis, a bridging therapy with low molecular weight heparin (LMWH) may be considered until 24 hours before surgery. This approach aims to mitigate the risk of thrombotic events during the period when Plavix is withheld. The LMWH can be resumed 12-24 hours after surgery if hemostasis is adequate, with Plavix restarted as soon as possible postoperatively, typically within 24 hours.

Key considerations in this management plan include:

• The timing of Plavix cessation and resumption
• The use of bridging anticoagulation therapy with LMWH
• Close monitoring of the patient's bleeding and thrombotic risk factors
• Multidisciplinary discussion involving the surgeon, anesthesiologist, and a hematologist or cardiologist to create a personalized perioperative anticoagulation plan. Given the high thrombotic risk in this patient, stopping Plavix 5 days preoperatively and implementing a bridging therapy is a prudent approach to balance the risks of bleeding and thrombosis, as supported by guidelines for managing patients on antiplatelet therapy undergoing surgery 1.

From the FDA Drug Label

5.3 Discontinuation of Clopidogrel Discontinuation of clopidogrel increases the risk of cardiovascular events. If clopidogrel must be temporarily discontinued (e.g., to treat bleeding or for surgery with a major risk of bleeding), restart it as soon as possible. When possible, interrupt therapy with clopidogrel for five days prior to such surgery. Resume clopidogrel as soon as hemostasis is achieved.

The recommended duration to stop Plavix (clopidogrel) preoperatively is 5 days before surgery, such as knee arthroscopy, especially in patients with a history of ischemic stroke and factor V Leiden 2. However, the decision to stop clopidogrel should be made on a case-by-case basis, considering the individual patient's risk of bleeding and cardiovascular events.

• Key considerations:
  • Risk of bleeding
  • Risk of cardiovascular events
  • Patient's medical history, including ischemic stroke and factor V Leiden It is essential to weigh these factors and consult with the patient's healthcare team to determine the best course of action.

From the Research

Perioperative Management of Plavix

• The management of patients on Plavix (clopidogrel) who are undergoing knee arthroscopy and have a history of factor V Leiden and ischemic stroke requires careful consideration of the risk of bleeding and thrombosis.
• According to the study by 3, factor V Leiden is associated with a lower risk of combined major and minor bleeding in patients with acute coronary syndromes treated with antiplatelet therapy.
• However, the study by 4 suggests that low-molecular-weight heparin (LMWH) may be effective in preventing venous thromboembolism (VTE) in patients with acute ischemic stroke, and that combination therapy with antiplatelet agents and LMWHs may be beneficial.

Duration of Plavix Discontinuation

• There is no clear evidence to guide the duration of Plavix discontinuation before knee arthroscopy in patients with a history of factor V Leiden and ischemic stroke.
• The study by 5 found that low-molecular-weight heparin was effective in improving outcomes at six months in patients with ischemic stroke treated within 48 hours of symptom onset.
• The study by 6 found that LMWH reduced the incidence of deep vein thrombosis (DVT) in patients with lower-limb immobilization, but the quality of evidence was moderate due to risk of selection and attrition bias.
• The study by 7 found no association between factor V Leiden and ischemic stroke risk in young adults, but this study did not address the specific question of Plavix discontinuation before surgery.

Considerations for Knee Arthroscopy

• Knee arthroscopy is a relatively low-risk procedure for bleeding, but the risk of VTE is still present, particularly in patients with a history of factor V Leiden and ischemic stroke.
• The decision to discontinue Plavix before knee arthroscopy should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history.
• Consultation with a cardiologist or hematologist may be necessary to determine the best course of action for patients with complex medical histories.