What medications should be avoided prior to an atrial ablation (catheter ablation) procedure?

From the Guidelines

Patients scheduled for an atrial ablation procedure should avoid taking certain medications prior to the procedure to minimize the risk of bleeding and other complications. The most critical medications to avoid are blood thinners, such as warfarin (Coumadin), dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis), and edoxaban (Savaysa), which should be discontinued 2-5 days before the procedure, depending on the specific medication and physician preference 1. Some key points to consider when stopping these medications include:

• The timing of the last dose of non-vitamin K antagonist oral anticoagulants (NOACs) before the procedure, with some studies suggesting that the last dose can be taken 12 hours before the start of the intervention 1
• The need for bridging therapy with heparin in patients with high thrombotic risk
• The importance of consulting with an electrophysiologist to determine the best approach for individual patients Additionally, antiplatelet medications like aspirin, clopidogrel (Plavix), prasugrel (Effient), and ticagrelor (Brilinta) may need to be stopped 5-7 days prior to the procedure 1. Other medications to avoid include:
• Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen, and diclofenac, which should be avoided for at least 48-72 hours before the procedure
• Herbal supplements with blood-thinning properties, including ginkgo biloba, garlic supplements, fish oil, and vitamin E, which should be discontinued 7-10 days before the procedure It is essential to note that the decision to stop or continue any medication should be made in consultation with an electrophysiologist, taking into account the individual patient's risk factors and medical history 1. The goal is to balance the risk of bleeding with the risk of thrombotic events, and the approach may vary depending on the specific patient and procedure.

From the FDA Drug Label

The following factors, alone or in combination, may be responsible for INCREASED PT/INR response: ENDOGENOUS FACTORS: ... EXOGENOUS FACTORS: Potential drug interactions with warfarin sodium tablets are listed below by drug class and by specific drugs. Classes of Drug also: other medications affecting blood elements which may modify hemostasis dietary deficiencies prolonged hot weather unreliable PT/INR determinations

• Increased and decreased PT/INR responses have been reported (oral) (17-Alkyl Penicillins, intravenous, Gout Treatment Agents Testosterone Derivatives) (fluoroquinolones) (topical) ogen dextran (intravaginal, oral, systemic) activator (t-PA) dextrothyroxine moricizine hydrochloride* tolbutamide diazoxide nalidixic acid tramadol diclofenac naproxen trimethoprim/sulfamethoxazole dicumarol neomycin urokinase diflunisal norfloxacin valdecoxib disulfiram ofloxacin valproate doxycycline olsalazine vitamin E erythromycin omeprazole zafirlukast esomeprazole oxandrolone zileuton ethacrynic acid oxaprozin ezetimibe oxymetholone fenofibrate pantoprazole The following factors, alone or in combination, may be responsible for DECREASED PT/INR response: ENDOGENOUS FACTORS: ... EXOGENOUS FACTORS: Potential drug interactions with warfarin sodium tablets are listed below by drug class and by specific drugs. Classes of Drugs also: diet high in vitamin K unreliable PT/INR determinations
• Increased and decreased PT/INR responses have been reported † Vitamins† Specific Drugs Reported: alcohol* warfarin sodium underdosage phenytoin* aminoglutethimide cyclophosphamide* pravastatin* amobarbital dicloxacillin prednisone* atorvastatin* ethchlorvynol primidone azathioprine glutethimide propylthiouracil* butabarbital griseofulvin raloxifene butalbital haloperidol ranitidine* carbamazepine meprobamate rifampin chloral hydrate* 6-mercaptopurine secobarbital chlordiazepoxide methimazole* spironolactone chlorthalidone moricizine hydrochloride* sucralfate cholestyramine* nafcillin trazodone clozapine paraldehyde vitamin C (high dose) corticotropin pentobarbital vitamin K cortisone phenobarbital Because a patient may be exposed to a combination of the above factors, the net effect of warfarin sodium tablets on PT/INR response may be unpredictable More frequent PT/INR monitoring is therefore advisable. Medications of unknown interaction with coumarins are best regarded with caution. When these medications are started or stopped, more frequent PT/INR monitoring is advisable. It has been reported that concomitant administration of warfarin and ticlopidine may be associated with cholestatic hepatitis Botanical (Herbal) Medicines Caution should be exercised when botanical medicines (botanicals) are taken concomitantly with warfarin sodium tablets. Few adequate, well-controlled studies exist evaluating the potential for metabolic and/or pharmacologic interactions between botanicals and warfarin sodium tablets Due to a lack of manufacturing standardization with botanical medicinal preparations, the amount of active ingredients may vary. This could further confound the ability to assess potential interactions and effects on anticoagulation. It is good practice to monitor the patient’s response with additional PT/INR determinations when initiating or discontinuing botanicals Specific botanicals reported to affect warfarin sodium tablets therapy include the following: Bromelains, danshen, dong quai (Angelica sinensis), garlic, Ginkgo biloba, ginseng, and cranberry products are associated most often with an INCREASE in the effects of warfarin sodium tablets. Coenzyme Q10 (ubidecarenone) and St John’s wort are associated most often with a DECREASE in the effects of warfarin sodium tablets. Some botanicals may cause bleeding events when taken alone (e.g., garlic and Ginkgo biloba) and may have anticoagulant, antiplatelet and/or fibrinolytic properties. These effects would be expected to be additive to the anticoagulant effects of warfarin sodium tablets. Conversely, other botanicals may have coagulant properties when taken alone or may decrease the effects of warfarin sodium tablets Some botanicals that may affect coagulation are listed below for reference; however, this list should not be considered all-inclusive. Many botanicals have several common names and scientific names. The most widely recognized common botanical names are listed Botanicals that contain coumarins with potential anticoagulant effects:
• Contains coumarins, has antiplatelet properties, and may have coagulant properties due to possible Vitamin K content. † Contains coumarins and has antiplatelet properties. ‡ Contains coumarins and salicylates. § Contains coumarins and has fibrinolytic properties. ¶ Has antiplatelet and fibrinolytic properties (Dong Quai) (German and Roman) Do not take or discontinue any other medication, including salicylates (e.g., aspirin and topical analgesics), other over-the-counter medications, and botanical (herbal) products except on advice of the physician. Avoid alcohol consumption. Discontinuation: Premature discontinuation increases risk of cardiovascular events. Discontinue 5 days prior to elective surgery that has a major risk of bleeding.

Medications to Avoid Prior to Atrial Ablation:

• Salicylates (e.g., aspirin and topical analgesics)
• Other over-the-counter medications
• Botanical (herbal) products
• Alcohol
• The following medications may increase the risk of bleeding and should be avoided or used with caution:
  • Antiplatelet agents (e.g., clopidogrel)
  • Anticoagulants (e.g., warfarin)
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., diclofenac, naproxen)
  • Selective serotonin reuptake inhibitors (SSRIs)
  • Certain antibiotics (e.g., fluoroquinolones)
  • Certain herbal supplements (e.g., Ginkgo biloba, garlic) It is recommended to discontinue medications that may increase the risk of bleeding at least 5 days prior to the procedure 2. Patients should consult their physician for specific guidance on medication management prior to atrial ablation.

From the Research

Medications to Avoid Prior to Atrial Ablation

To minimize the risk of stroke and procedure-related bleeding during catheter ablation for atrial fibrillation (AF) and atrial flutter (AFL), certain medications should be avoided or managed carefully prior to the procedure. The key considerations include:

• Anticoagulants: The management of anticoagulation is crucial in the peri-procedural period 3, 4, 5, 6, 7.
• Antiplatelet agents: Aspirin may be used in certain cases, but its use should be carefully considered in the context of other anticoagulants 4, 6.

Specific Medications

The following points outline specific medications and their management:

• Warfarin: It is typically stopped 2-5 days before the procedure, but in some cases, it may be continued uninterrupted 4, 5, 7.
• New oral anticoagulants (NOACs) like dabigatran and rivaroxaban: These should be held for a specified period before the procedure, typically 24 hours for dabigatran and 36 hours for rivaroxaban 7.
• Low molecular weight heparin (LMWH): This may be used as a bridging anticoagulant in certain cases, especially when warfarin is stopped before the procedure 4, 5, 6.
• Aspirin: It may be started a few days before the procedure and continued afterwards, depending on the patient's risk profile 4, 6.

Considerations for Medication Management

The decision on which medications to avoid and how to manage them should be based on the individual patient's risk factors, including the risk of thromboembolism and bleeding 3, 4, 5, 6, 7. Factors such as the CHADS2 score can help guide these decisions 5, 6.