ACCP gave detailed Clopidogrel guidance in their 2008 guideline which
follows, updated with post-stent dual antiplatelet therapy guidance in
the 2012 guideline.
- for patients with low risk of cardiac event, stop Clopidogrel/antiplatelet agents before surgery.
- for patients with high risk of cardiac event (exclusive of stents), continue Clopidogrel/antiplatelet agents during surgery.
-
for patients on dual antiplatelet therapy who received bare metal stent
within 6 weeks or drug eluting stent within 6 months, deferral of
surgery is recommended, but if surgery must be undertaken, continue dual
antiplatelet therapy.
- for patients with stents whose
antiplatelet agent will be stopped, there is no good data to support use
of bridging heparins, direct thrombin inhibitors, or glycoprotein
IIb/IIIa injibitors and thus they are not recommended.
- when stopping Clopidogrel, do so at least 5 days and preferably closer to 10 days before surgery.- for patients whose Clopidogrel has been stopped, resume 24 hours post-op or next morning if surgical hemostasis is good.
-
unlike Aspirin, in the setting of minor dental, dermatologic, and
cataract procedures, Clopidogrel should be continue or stopped according
to the cardiac event risk as described above.
ACC on topic of Clopidogrel and other similar P2Y12-inhibitor agents says:
-
for patients having urgent surgery during the first 4-6 weeks after BMS
or DES implantation, DAPT (dual antiplatelet therapy) should be
continued unless the relative risk of bleeding outweighs the benefit of
the prevention of stent thrombosis (I, C)
- for stented patients
who must undergo a surgery which mandates discontinuation of
P2Y12-injibitor (Clopidogrel and similar) therapy, continue the Aspirin
if possible and restart the P2Y12-inhibitor as soon as possible after
surgery (ACC I, C).
- mgmt of perioperative antiplatelet therapy
should be determined by a consensus of the surgeon, anesthesiologist,
cardiologist, and patient, who should weight the relative risk of
bleeding versus prevention of stent thrombosis (I, C).
- ACC
offers a new proposed algorithm on surgery timing and medication mgmt
decisions for post-stent patients on DAPT. But humbly this editor finds
that the algorithm leaves too many situations and questions unanswered
to be useful for inclusion here. We should await further clarification.