Management of Medications Before Cardiac Catheterization
For patients going to the cardiac catheterization lab, heparin should be continued, aspirin should be continued, Entresto (sacubitril/valsartan) should be temporarily discontinued at least 24 hours before the procedure, and carvedilol may be continued. 1
Specific Medication Recommendations
Heparin
- Continue heparin as it is the standard anticoagulant for patients undergoing cardiac catheterization 1
- Unfractionated heparin (UFH) is preferred over low-molecular-weight heparin (LMWH) for cardiac catheterization procedures 1
- For pediatric patients, a UFH bolus of 100 U/kg (up to 5000-U maximum) is recommended for cardiac catheterization with arterial access 1
- Monitoring of anticoagulation during cardiac catheterization should be performed with ACT (activated clotting time) measurements, aiming for >200 seconds 1
Aspirin
- Continue aspirin throughout the procedure 1
- Aspirin provides important antiplatelet protection during cardiac catheterization and should not be discontinued 1
- Aspirin alone is not sufficient for procedural thromboprophylaxis during cardiac catheterization and should be combined with heparin 1
Entresto (Sacubitril/Valsartan)
- Temporarily discontinue Entresto at least 24 hours before the procedure 1
- NOACs (including components of combination drugs like Entresto) should be discontinued before patients are taken to the cath lab 1
- The procedure should be performed at least 12-24 hours after the last intake of Entresto 1
- Sacubitril/valsartan can cause hypotension, which may complicate catheterization procedures 2, 3
Carvedilol
- Carvedilol may be continued through the cardiac catheterization procedure 1
- Beta-blockers are generally continued perioperatively to prevent withdrawal symptoms and cardiovascular events 1
- There are no specific recommendations to discontinue carvedilol before cardiac catheterization in the guidelines 1
Procedural Considerations
Periprocedural Anticoagulation
- Unfractionated heparin (70 IU/kg) or bivalirudin is preferred over enoxaparin during the procedure 1
- UFH should be administered to target ACT or aPTT levels per standard clinical practice 1
- For patients pre-treated with fondaparinux, additional anticoagulant with anti-IIa activity should be administered at the time of PCI 1
Post-Procedure Management
- Resume Entresto after the procedure once the patient is hemodynamically stable 1, 2
- Continue dual antiplatelet therapy if indicated for the patient's condition 1
- Monitor for hypotension after restarting Entresto, especially in combination with other antihypertensive medications 3, 4
Special Considerations
High Bleeding Risk
- For patients at high risk of bleeding, consider using radial rather than femoral access 1
- In patients with high bleeding risk undergoing PCI, discontinuation of P2Y12 receptor inhibitor therapy after 3-6 months should be considered 1
High Thrombotic Risk
- For patients at high risk of stent thrombosis, more aggressive anticoagulation during the procedure may be warranted 1
- In patients with recent stent placement (<1 month for BMS, <3 months for DES), the risk of stent thrombosis with medication discontinuation must be carefully weighed 1
By following these evidence-based recommendations, the risk of both thrombotic and bleeding complications during cardiac catheterization can be minimized while maintaining appropriate cardiovascular protection.