What are the post-angiogram management guidelines for patients?

Post-Angiogram Management

For patients undergoing diagnostic coronary angiography, continue aspirin indefinitely, manage anticoagulation based on the specific agent used (UFH for 48 hours, enoxaparin/fondaparinux up to 8 days), achieve hemostasis with 2 hours of compression for radial access, and assess left ventricular function to guide further risk stratification. 1, 2, 3

Immediate Post-Procedure Care

Access Site Management

For transradial access, apply hemostatic compression for exactly 2 hours to optimize the balance between preventing radial artery occlusion and minimizing access site bleeding or hematoma. 3 Shorter durations (<90 minutes or 90 minutes) significantly increase the risk of access site hematoma (odds ratio 3.61 and 2.39 respectively), while durations beyond 2 hours do not provide additional safety benefit. 3

For transfemoral access via 6-Fr catheters, selected low-risk patients can be safely ambulated at 2 hours post-procedure if they meet specific criteria: 4

• Easy arterial access achieved
• Compression time <15 minutes
• No hematoma formation within first 2 hours
• Blood pressure <180/100 mmHg
• No blood oozing at 2-hour assessment

Patients requiring longer observation (4-6 hours bed rest) include those with: 4

• Difficult arterial access
• Prolonged compression time (>15 minutes)
• Early hematoma formation
• Uncontrolled hypertension (BP >180/100 mmHg)
• Use of sheaths >5Fr (associated with higher complication rates) 5

Antiplatelet Therapy Management

Continue aspirin 75-100 mg daily indefinitely for all patients. 1, 2, 6 This represents Level of Evidence A and should be maintained regardless of findings on angiography. 1

For patients with evidence of coronary atherosclerosis (even without flow-limiting stenoses), initiate long-term aspirin and secondary prevention measures. 1 This includes patients with luminal irregularities or intravascular ultrasound-demonstrated lesions. 1

Anticoagulant Therapy Management Based on Agent Used

The management strategy differs significantly based on which anticoagulant was administered:

Unfractionated Heparin (UFH): 1, 2

• Continue for at least 48 hours or until discharge if given before diagnostic angiography (Level of Evidence: A)
• For patients with no significant obstructive CAD found, discontinue at physician's discretion 1

Enoxaparin: 1, 2

• Continue for duration of hospitalization, up to 8 days, if given before diagnostic angiography (Level of Evidence: A)
• Do not discontinue prematurely as this increases thrombotic risk 1

Fondaparinux: 1, 2

• Continue for duration of hospitalization, up to 8 days, if given before diagnostic angiography (Level of Evidence: B)

Bivalirudin: 1

• Either discontinue or continue at 0.25 mg/kg/hour for up to 72 hours at physician's discretion (Level of Evidence: B)

Management Based on Angiographic Findings

No Significant Obstructive CAD Found

Antiplatelet and anticoagulant therapy should be managed at clinician's discretion (Level of Evidence: C). 1 However, if any evidence of coronary atherosclerosis is present (luminal irregularities, intravascular ultrasound-demonstrated lesions), prescribe long-term aspirin and secondary prevention measures. 1

Obstructive CAD Found - Medical Management Selected

Implement the following regimen: 1

1. Continue aspirin indefinitely (Level of Evidence: A) 1, 2, 6

2. Administer P2Y12 inhibitor loading dose if not given before angiography: 1, 2

   • Clopidogrel 300-600 mg loading dose, then 75 mg daily
   • OR Ticagrelor 180 mg loading dose, then 90 mg twice daily (with aspirin 81 mg daily)
   • Continue for up to 12 months (Level of Evidence: B) 1

3. Discontinue intravenous GP IIb/IIIa inhibitor if started previously (Level of Evidence: B) 1

4. Continue anticoagulation as outlined above based on specific agent 1, 2

PCI Selected as Management Strategy

Continue aspirin and administer P2Y12 inhibitor loading dose if not started before diagnostic angiography (Level of Evidence: A). 1, 2

For high-risk patients (troponin-positive), it is reasonable to administer intravenous GP IIb/IIIa inhibitor (abciximab, eptifibatide, or tirofiban) if not started before angiography (Class IIa, Level of Evidence: A). 1

Discontinue anticoagulant therapy after PCI for uncomplicated cases (Level of Evidence: B). 1

CABG Selected as Management Strategy

Continue aspirin (Level of Evidence: A). 1, 2

Discontinue P2Y12 inhibitors before surgery: 1, 2

• Clopidogrel: 5-7 days before elective CABG (Level of Evidence: B)
• Prasugrel: at least 7 days before surgery 2
• Ticagrelor: at least 5 days before surgery 1, 2

More urgent surgery may be performed if the incremental bleeding risk is acceptable (Level of Evidence: C). 1

Discontinue GP IIb/IIIa inhibitors 4 hours before CABG (Level of Evidence: B). 1

Anticoagulant management: 1

• Continue UFH (Level of Evidence: B)
• Discontinue enoxaparin 12-24 hours before CABG, dose with UFH per institutional practice (Level of Evidence: B)
• Discontinue fondaparinux 24 hours before CABG, dose with UFH (Level of Evidence: B)
• Discontinue bivalirudin 3 hours before CABG, dose with UFH (Level of Evidence: B)

Risk Stratification and Further Evaluation

Left Ventricular Function Assessment

Measure LVEF for all patients in whom an initial conservative strategy is selected and no subsequent features appear requiring angiography (recurrent symptoms/ischemia, heart failure, serious arrhythmias) (Level of Evidence: B). 1, 2

If LVEF ≤0.40, it is reasonable to perform diagnostic angiography (Class IIa, Level of Evidence: B). 1, 2

If LVEF >0.40, it is reasonable to perform stress testing (Class IIa, Level of Evidence: B). 1, 2

Monitoring for Complications

Access Site Complications

Sonographic follow-up detects major access site complications in 4.2% of cases, including pseudoaneurysm (most common major complication), major hematoma, arteriovenous fistula, arterial dissection, and thrombosis. 5

Risk factors for major complications include: 5

• Age >60 years
• Sheath size >5Fr

For transradial access, remain vigilant for: 7

• Radial artery occlusion (most common complication)
• Hematoma formation
• Pseudoaneurysm
• Arteriovenous fistula
• Nerve injury

Clinical Monitoring

Monitor continuously for at least 24 hours for: 2, 8, 6

• Recurrent ischemic symptoms
• Hemodynamic instability
• Cardiac arrhythmias
• Access site bleeding or hematoma expansion

Common Pitfalls to Avoid

Never discontinue aspirin - it should be continued indefinitely regardless of angiographic findings (Level of Evidence: A). 1, 2, 6

Do not prematurely discontinue enoxaparin or fondaparinux - these should be continued for the full duration of hospitalization up to 8 days if started before angiography. 1, 2

Avoid NSAIDs (except aspirin) during hospitalization due to increased risks of mortality, reinfarction, hypertension, heart failure, and myocardial rupture. 8, 6

Do not use immediate-release dihydropyridine calcium channel blockers without adequate beta-blockade. 8, 6

Avoid intravenous ACE inhibitors within the first 24 hours due to increased risk of hypotension. 8, 6