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Patients on Plavix® are at increased risk for bleeding if they require surgical procedures, and recent literature (click here*) suggests that many of these patients do not require Plavix therapy at all. In addition, up to 10 percent may have some degree of "resistance" and may not be deriving benefit from the drug. A Task Force comprised of physician representatives from the departments of Anesthesia, Surgery, Cardiology, Emergency Medicine and Pathology, along with colleagues in Pharmacy and Nursing, has developed the following guidelines for Plavix therapy: Indications for Plavix Therapy - Unstable angina
- Acute coronary syndrome (NSTEMI/STEMI)
- Post PCI/Stent placement
- Documented aspirin allergy in patient requiring anti-platelet therapy
- Intracranial/carotid stent
- Brachytherapy
- Peripheral stent (renal, inguinal, popliteal)
- Cerebrovascular disease with recurrent ischemia in patients refractory to aspirin or aspirin and Dipyridamole
Note: Clopidogrel is not indicated in stroke patients. Patients with prior strokes who are currently receiving Clopidogrel should be switched to aspirin or aspirin and Dipyridamole. Contraindications - Active bleeding
- Hypersensitivity to Clopidogrel or any component of the product
Perioperative management of patients on Clopidogrel - ELECTIVE - Whenever possible, delay surgery and hold Clopidogrel five to seven days prior to surgery. Consultation may be indicated.
- For patients with drug-eluting stents, surgery should be delayed for six months after stent implantation. For selected high-risk patients, "bridging" therapy with a short acting anti-platelet agent may be indicated.
- Any patient with a coronary stent who develops chest pain or ST segment elevation in the perioperative setting should be suspected of having acute thrombosis and treated as a "Code White." Immediate cardiac catheterization laboratory intervention is essential to prevent perioperative myocardial infarction, which carries a 30 to 50 percent mortality risk.
Perioperative management of patients on Clopidogrel - EMERGENT - If surgery must be performed in patients at high-risk for bleeding, consider administering DDAVP (0.3 microgram per kg) and 1 platelet pheresis concentrate (equivalent to 6-10 individual platelet packs) immediately prior to surgery.
- An additional dose of DDAVP or an additional platelet transfusion may be required to treat observed bleeding. Follow other coagulation parameters - PTT, INR -- as there is no specific test to monitor Clopidogrel intraoperatively.
Postoperative management of patients on Clopidogrel - Restart Clopidogrel after the first postoperative day (apply clinical judgment).
(*"Role of Clopidogrel in Managing Atherothrombotic Cardiovascular Disease," Annals of Internal Medicine, March 20, 2007)
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