Do you hold anticoagulant medication for heart catheterization?

Management of Anticoagulation for Heart Catheterization

For patients on anticoagulant therapy, anticoagulation should be temporarily discontinued before heart catheterization procedures based on specific timing recommendations for each agent to minimize bleeding risk while maintaining patient safety.

General Principles for Anticoagulation Management

The European Society of Cardiology (ESC) and American College of Cardiology (ACC) guidelines provide clear recommendations for managing anticoagulation during cardiac procedures, including heart catheterization. The management strategy depends on:

1. Type of anticoagulant
2. Access route (radial vs. femoral)
3. Patient's thrombotic risk
4. Renal function

Specific Recommendations by Anticoagulant Type

Direct Oral Anticoagulants (DOACs)

For patients on DOACs undergoing heart catheterization, the following hold times are recommended 1:

• Apixaban:

  • Transradial approach: Hold ≥24 hours if CrCl ≥30 ml/min; ≥36 hours if CrCl 15-29 ml/min
  • Transfemoral approach: Hold ≥48 hours if CrCl ≥30 ml/min; longer if CrCl <30 ml/min

• Dabigatran:

  • Transradial approach: Hold ≥24 hours if CrCl ≥50 ml/min; ≥36 hours if CrCl 30-49 ml/min
  • Transfemoral approach: Hold ≥48 hours if CrCl ≥50 ml/min; longer if CrCl <50 ml/min

• Rivaroxaban/Edoxaban:

  • Transradial approach: Hold ≥24 hours if CrCl ≥30 ml/min; ≥36 hours if CrCl 15-29 ml/min
  • Transfemoral approach: Hold ≥48 hours if CrCl ≥30 ml/min; longer if CrCl <30 ml/min

Vitamin K Antagonists (Warfarin)

• For elective procedures: Hold warfarin and allow INR to decrease to appropriate level (typically <1.8 for catheterization)
• No bridging with heparin is typically necessary for heart catheterization 1

Antiplatelet Therapy

• Aspirin: Continue aspirin (81-325 mg) throughout the perioperative period 1
• P2Y12 inhibitors (for non-emergent procedures) 1:
  • Ticagrelor: Hold for at least 3 days
  • Clopidogrel: Hold for at least 5 days
  • Prasugrel: Hold for at least 7 days

Procedural Anticoagulation

During the heart catheterization procedure itself, anticoagulation is recommended for all patients 1:

• Unfractionated heparin (UFH): Recommended as routine (Class I, Level C)

  • 70-100 U/kg IV bolus when no GP IIb/IIIa inhibitor is planned
  • 50-70 U/kg IV bolus with GP IIb/IIIa inhibitors

• Enoxaparin: Should be considered (Class IIa, Level B)

  • 0.5 mg/kg IV bolus

• Bivalirudin: May be considered (Class IIb, Level A)

  • 0.75 mg/kg IV bolus followed by 1.75 mg/kg/h infusion 2

Special Considerations

Patients with High Thrombotic Risk

For patients at high thrombotic risk (recent stent placement, mechanical heart valves):

• Radial access is strongly preferred to minimize bleeding risk 1
• Consider shorter hold times for anticoagulants when possible
• For patients with recent coronary stents, the Heart Team should estimate individual bleeding and ischemic risks to guide management 1

Post-Procedural Management

• Anticoagulation should be discontinued after PCI unless there is a compelling reason to continue such therapy 1
• For patients requiring long-term anticoagulation, restart anticoagulant therapy when adequate hemostasis is achieved 1

Common Pitfalls to Avoid

1. Avoid routine bridging with heparin for patients on warfarin undergoing heart catheterization, as this increases bleeding risk without reducing thrombotic events 1

2. Don't discontinue aspirin in patients undergoing heart catheterization, as the increased bleeding risk is minimal compared to the thrombotic risk 1, 3

3. Avoid crossover between different anticoagulants (especially between UFH and LMWH) as this increases bleeding risk 1

4. Don't use fondaparinux as the sole anticoagulant during PCI due to increased risk of catheter thrombosis (Class III: Harm) 1

By following these evidence-based recommendations, clinicians can minimize both bleeding and thrombotic complications during heart catheterization procedures.