Is it safe to proceed with Left Heart Catheterization (LHC) in a patient on daptomycin (Cubicin)?

Safety of Left Heart Catheterization in Patients on DAPT

It is safe to proceed with left heart catheterization (LHC) in patients on dual antiplatelet therapy (DAPT), and there is no need to discontinue DAPT prior to the procedure.

Risk Assessment for LHC

Left heart catheterization is a common diagnostic procedure with an extremely low complication rate. According to a large retrospective study of 43,786 diagnostic LHC procedures, major complications occurred in only 0.082% of cases (8.2 per 10,000 procedures) 1.

Potential Complications of LHC

• Vascular injury/perforations/tears
• Cardiac perforation
• Cardiac valve injury
• Blood loss requiring transfusion
• Arrhythmias
• Stroke
• Death (extremely rare)

DAPT and Cardiac Catheterization

Dual antiplatelet therapy typically consists of aspirin plus a P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel). While DAPT increases bleeding risk, this must be balanced against the risk of thrombotic events if DAPT is discontinued.

Key Considerations:

1. Procedural Bleeding Risk:

   • LHC is considered a low bleeding risk procedure
   • The risk of major bleeding complications during diagnostic catheterization is minimal (0.082%) 1

2. Thrombotic Risk if DAPT Discontinued:

   • Discontinuation of DAPT, especially in patients with recent coronary stenting, can lead to stent thrombosis
   • Stent thrombosis carries a mortality rate of 20-45%

Guidelines for Antiplatelet Management During LHC

The American Heart Association guidelines for cardiac catheterization do not recommend routine discontinuation of antiplatelet therapy prior to diagnostic catheterization 2. In fact, maintaining DAPT is important in patients with:

• Recent coronary stent placement
• Acute coronary syndrome
• High thrombotic risk

Approach to LHC in Patients on DAPT

1. Pre-procedure:

   • Continue DAPT without interruption
   • Ensure proper hydration status
   • Check complete blood count and coagulation parameters

2. During procedure:

   • Use radial approach when possible (reduces bleeding risk)
   • Minimize catheter exchanges
   • Use smaller French size catheters if appropriate

3. Post-procedure:

   • Ensure meticulous hemostasis
   • Consider extended compression time at access site
   • Close monitoring for bleeding at access site

Special Considerations

High Bleeding Risk Patients

For patients with both high bleeding risk and high thrombotic risk:

• Consider femoral access with vascular closure device
• Use ultrasound guidance for access
• Consider hospitalization for close monitoring post-procedure

Timing of LHC After Stent Placement

If LHC is elective and not urgent:

• For bare metal stents: Consider delaying LHC until at least 4 weeks after stent placement
• For drug-eluting stents: Consider delaying LHC until at least 3-6 months after stent placement

Conclusion

The evidence strongly supports proceeding with LHC in patients on DAPT without discontinuation of antiplatelet therapy. The extremely low rate of major complications with diagnostic catheterization (0.082%) 1 does not justify the thrombotic risk associated with interrupting DAPT, especially in high-risk patients.