Clopidogrel implantation

Clopidogrel should be considered for most patients, but the duration of therapy is individualized according to the type of ACS and whether the patient is treated medically or undergoes stent implantation. 

For patients with STEMI treated medically without revascularization, clopidogrel can be given for 14 to 28 days. If a stent has been implanted, clopidogrel can be continued for up to 12 months in patients at low risk for bleeding. 

Eisenstein EL, Anstrom KJ, Kong DF, et al. Clopidogrel use and long-term clinical outcomes after drug-eluting stent implantation. JAMA 2007 297 159-168. 

Thus, clopidogrel (LD300 mg + 75 mg/day for one month) is the standard of care after bare metallic stent implantation. 

Pekdemir H, Cin VG, Camsari A, et al. A comparison of I-month and 6-month clopidogrel therapy on clinical and angiographic outcome after stent implantation. Heart Vessels 2003 18(3) 123-129. 

Intravenous antibiotics are given before and after the procedure. Endocarditis prophylaxis is recommended for six months. Coumadin type drugs should be administered at least for 45 days after the Watchman implantation procedure with an INR between two and three in combination with 100 mg aspirin. When complete endothelialization is likely with no or only little flowthrough the device, coumadin can be discontinued and clopidogrel 75 mg/day is given until six months follow-up examination. In the absence of thrombus or flow in the appendage at TEE at six months, clopidogrel is stopped and aspirin therapy 100 mg/day is continued indefinitely If thrombus formation is seen, obviously coumadin therapy is restarted. 

Before intervention heparin is administered (100 U/kg) in addition to endocarditis prophylaxis (e.g., cefuroxime, l,5g, i.v.). Endocarditis prophylaxis is repeated afterthe procedure. Aspirin (100mg, p.d.) and clopidogrel (75mg/day, p.o.) are prescribed for six months after implantation. The incidence of thrombus formation varies between devices (50). If thrombus is seen during follow-up, coumadin therapy should be commenced. 

Similarly, the addition of calcium channel blockers in patients taking clopidogrel increased platelet reactivity in 162 patients after percutaneous intervention with stent implantation [174 ]. 

Kammer RT. Successful clopidogrel desensitization after drug-eluting stent implantation. J Invasive Cardiol 2009 21(3) 134-5. 

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