What medications should be held before catheterization (cath) for possible unstable angina?

Medications to Hold Before Cardiac Catheterization for Possible Unstable Angina

For patients with possible unstable angina undergoing cardiac catheterization, clopidogrel and other P2Y12 inhibitors should be discontinued 5-7 days before the procedure if CABG might be needed, while aspirin should be continued throughout. 1

Antiplatelet Medications

P2Y12 Receptor Inhibitors

• Clopidogrel: Discontinue 5-7 days before elective CABG 1
• Prasugrel: Discontinue at least 7 days before CABG 1
• Ticagrelor: Discontinue at least 5-7 days before CABG 1

Glycoprotein IIb/IIIa Inhibitors

• Eptifibatide/Tirofiban: Discontinue 4 hours before CABG 1
• Abciximab: Should not be administered to patients in whom PCI is not planned 1

Other Antiplatelet Agents

• Aspirin: Continue throughout the perioperative period 1

Anticoagulants

Parenteral Anticoagulants

• Unfractionated Heparin (UFH): Continue if CABG is planned 1
• Enoxaparin: Discontinue 12-24 hours before CABG 1
• Fondaparinux: Discontinue 24 hours before CABG 1
• Bivalirudin: Discontinue 3 hours before CABG 1, 2

Decision Algorithm Based on Clinical Scenario

If CABG is Likely (Based on Risk Factors or Known Coronary Anatomy):

1. Hold P2Y12 inhibitors:
   • Clopidogrel: 5-7 days before procedure
   • Prasugrel: 7 days before procedure
   • Ticagrelor: 5-7 days before procedure
2. Continue aspirin
3. Manage anticoagulants as noted above

If PCI is More Likely (Low Risk for CABG):

1. Continue aspirin
2. P2Y12 inhibitors can be continued or loading dose given on the catheterization table if PCI is performed 1
3. Consider GP IIb/IIIa inhibitors for high-risk patients (troponin-positive) 1

If Diagnostic Catheterization Only (No Intervention Planned):

1. Continue aspirin
2. Consider holding P2Y12 inhibitors if there's any possibility of CABG
3. Anticoagulant therapy can be managed at the discretion of the clinician 1

Important Clinical Considerations

• Bleeding Risk: Continuing P2Y12 inhibitors increases bleeding risk if urgent CABG is needed. In the CURE study, patients who underwent CABG within 5 days of stopping clopidogrel had higher rates of major bleeding (9.6% vs 6.3%) 1

• Urgent Cases: For unstable patients requiring immediate catheterization, the risk of delaying the procedure must be weighed against the increased bleeding risk if CABG is needed. In these cases, experienced surgeons may perform "early" bypass surgery at acceptable incremental bleeding risk 1

• Institutional Practices: Some hospitals delay starting clopidogrel until after diagnostic catheterization when the coronary anatomy is known and the need for CABG is determined 1

• Monitoring: For patients on anticoagulants, appropriate laboratory monitoring should be performed to ensure adequate reversal before invasive procedures

• Common Pitfall: Failing to recognize that aspirin should be continued throughout the perioperative period, even when other antiplatelet agents are discontinued 1

Remember that these recommendations focus on optimizing outcomes by balancing the risk of thrombotic events against the risk of perioperative bleeding complications.