Should anticoagulants (blood thinners) and antiplatelets (platelet inhibitors) be stopped prior to coronary angiography?

Management of Anticoagulants and Antiplatelets Prior to Coronary Angiography

For diagnostic coronary angiography, aspirin should be continued, while P2Y12 inhibitors (clopidogrel, prasugrel, ticagrelor) and most anticoagulants can be continued or managed based on the anticipated post-angiography strategy. 1

Antiplatelet Management

Aspirin

• Continue aspirin through diagnostic coronary angiography 1
• Aspirin should be maintained at 75-325 mg daily regardless of whether the patient proceeds to PCI, CABG, or medical management 1

P2Y12 Inhibitors (Clopidogrel, Prasugrel, Ticagrelor)

For diagnostic angiography alone:

• P2Y12 inhibitors can be continued through diagnostic coronary angiography if the patient is already taking them 1
• If not already on therapy, a loading dose can be administered after coronary anatomy is defined and management strategy is determined 1

If CABG is anticipated or becomes necessary:

• Clopidogrel should be discontinued 5-7 days before elective CABG 1
• Prasugrel should be discontinued at least 7 days before CABG 1, 2
• Ticagrelor should be discontinued at least 3-7 days before CABG 1
• More urgent surgery may be performed by experienced surgeons if the bleeding risk is acceptable, though CABG-related bleeding rates are substantially higher when P2Y12 inhibitors are given within 3 days of surgery 1, 2

GP IIb/IIIa Inhibitors

• If started before angiography, discontinue eptifibatide or tirofiban 4 hours before CABG 1
• These agents may be initiated after angiography in high-risk patients (troponin-positive) proceeding to PCI 1

Anticoagulant Management

Unfractionated Heparin (UFH)

• Continue UFH through diagnostic angiography and during any subsequent procedures 1
• UFH should be continued for at least 48 hours or until discharge if medical management is selected post-angiography 1

Low Molecular Weight Heparin (Enoxaparin)

• Discontinue enoxaparin 12-24 hours before CABG and transition to UFH 1
• If medical management or PCI is selected, continue enoxaparin for the duration of hospitalization, up to 8 days 1

Fondaparinux

• Discontinue fondaparinux 24 hours before CABG and dose with UFH 1
• If medical management is selected, continue for duration of hospitalization, up to 8 days 1

Bivalirudin

• Discontinue bivalirudin 3 hours before CABG and dose with UFH 1
• After diagnostic angiography with medical management, either discontinue or continue at 0.25 mg/kg/hour for up to 72 hours at physician's discretion 1

Warfarin

• Warfarin can be continued uninterrupted for diagnostic coronary angiography 3, 4
• Research demonstrates that uninterrupted warfarin (INR 2.0-3.0) does not increase vascular access site complications compared to heparin bridging for transfemoral coronary angiography 3
• Elective coronary angiography and PCI can be safely performed with uninterrupted warfarin therapy using vascular closure devices 4

Direct Oral Anticoagulants (DOACs)

• Rivaroxaban, apixaban, edoxaban, and dabigatran should be stopped 1-2 days before CABG, depending on the specific drug and renal function 1

Post-Angiography Management Strategy

If PCI is Selected:

• Continue aspirin 1
• Administer P2Y12 inhibitor loading dose if not already given 1
• Discontinue anticoagulant therapy after uncomplicated PCI 1

If Medical Management is Selected:

• Continue aspirin 1
• Administer P2Y12 inhibitor loading dose if CAD is found and not previously given 1
• Continue anticoagulants as outlined above based on the specific agent 1

If CABG is Selected:

• Follow the discontinuation timelines outlined above for each specific agent 1

Critical Pitfalls to Avoid

• Do not routinely discontinue aspirin before diagnostic coronary angiography—it should be continued throughout 1, 5
• Avoid starting prasugrel in patients likely to undergo urgent CABG, as bleeding risk is substantial 2
• Do not use bridging therapy with GP IIb/IIIa inhibitors, cangrelor, or LMWH in patients with coronary stents requiring antiplatelet interruption for surgery, except in highly selected high-risk cases 1
• Premature discontinuation of antiplatelet therapy after PCI increases risk of stent thrombosis, MI, and death 2
• Platelet transfusions are less effective if given within 6 hours of prasugrel loading dose or 4 hours of maintenance dose 2