When to stop and start Direct Oral Anticoagulants (DOACs) before and after left heart catheterization with or without Percutaneous Coronary Intervention (PCI)?

DOAC Management for Left Heart Catheterization ± PCI

Direct Answer

For elective left heart catheterization with or without PCI, hold DOACs for 24 hours (transradial) or 48 hours (transfemoral) in patients with normal renal function (CrCl ≥30 mL/min), and resume within 24 hours post-procedure once hemostasis is achieved; for emergency procedures (STEMI or high-risk NSTEMI), stop the DOAC immediately and proceed without delay. 1

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Pre-Procedure Management: When to STOP DOACs

Emergency Procedures (STEMI or High-Risk NSTEMI)

• Stop anticoagulation immediately and proceed to catheterization without delay 1
• Do not wait for DOAC levels to decline 1
• Activated clotting time (ACT) is not a reliable indicator of anticoagulation status in DOAC patients 1
• Consider reversal agents (idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors) only in life-threatening bleeding scenarios 2

Elective or Urgent Procedures (Can Be Safely Deferred)

The 2020 ACC Expert Consensus provides the most comprehensive, kidney function-based approach for DOAC interruption 1:

Apixaban:

• Transradial approach: Hold 24 hours if CrCl ≥30 mL/min; 36 hours if CrCl 15-29 mL/min 1
• Transfemoral approach: Hold 48 hours if CrCl ≥30 mL/min; 72 hours if CrCl <29 mL/min 1

Rivaroxaban:

• Transradial approach: Hold 24 hours if CrCl ≥30 mL/min; 36 hours if CrCl 15-29 mL/min 1
• Transfemoral approach: Hold 48 hours if CrCl ≥30 mL/min; 72 hours if CrCl <29 mL/min 1

Edoxaban:

• Transradial approach: Hold 24 hours if CrCl ≥30 mL/min; 36 hours if CrCl 15-29 mL/min 1
• Transfemoral approach: Hold 48 hours if CrCl ≥30 mL/min; 72 hours if CrCl <29 mL/min 1

Dabigatran (requires longer interruption due to renal elimination):

• Transradial approach: Hold 24 hours if CrCl ≥80 mL/min; 36 hours if CrCl 50-79 mL/min; 48 hours if CrCl 30-49 mL/min; 72 hours if CrCl 15-29 mL/min 1
• Transfemoral approach: Hold 48 hours if CrCl >80 mL/min; 72 hours if CrCl 50-79 mL/min; 96 hours if CrCl 30-49 mL/min; 120 hours if CrCl 15-29 mL/min 1

Key Considerations for Pre-Procedure Planning

• Always assess recent creatinine clearance using the Cockcroft-Gault formula before determining hold duration 1, 3
• Do NOT use heparin bridging - this increases bleeding risk without reducing thrombotic events 1, 3, 4, 5
• For diagnostic catheterization only (no PCI planned), the same interruption guidelines apply 1
• Radial access is strongly preferred when feasible to minimize bleeding risk 1, 6

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Intra-Procedure Management

Anticoagulation During the Procedure

• Use standard intraprocedural anticoagulation (unfractionated heparin 70 IU/kg, LMWH, or bivalirudin) per local practice 1, 7
• Target ACT or aPTT levels according to standard clinical practice 1
• Bivalirudin may be preferred due to its very short half-life 1

Access Site Strategy

• Strongly prefer transradial access to minimize bleeding complications, particularly in patients who were recently on anticoagulation 1, 6
• Use vascular closure devices for transfemoral access when radial is not feasible 1
• Crossover to femoral access may be necessary in 5-10% of radial cases 1

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Post-Procedure Management: When to RESTART DOACs

Timing of Resumption

Resume DOACs within 24 hours after uncomplicated catheterization/PCI once adequate hemostasis is confirmed 1, 8. The ACC guidelines provide specific timing 1:

• As early as 6 hours post-procedure if hemostasis is secure and no bleeding complications 1, 3
• Most commonly the evening of the procedure day for once-daily evening dosing 1
• Next morning for once-daily morning dosing 1
• Evening of procedure day for twice-daily regimens 1

Pre-Restart Assessment Checklist

Before restarting anticoagulation, evaluate 1, 8:

• Access site hemostasis - this is the primary consideration 1, 8
• History of recent bleeding 1
• Body habitus (obese patients with transfemoral access require extra caution) 1
• Platelet abnormalities (qualitative or quantitative) 1
• Post-procedure renal function (may require dose adjustment) 1

Dosing Considerations Post-PCI

• For atrial fibrillation patients on rivaroxaban: Use 15 mg daily (not 20 mg) if CrCl >50 mL/min while on dual antiplatelet therapy, then increase to 20 mg daily once antiplatelet therapy is stopped 1
• For all other DOACs: Use FDA-approved doses appropriate for the indication 1
• Reassess renal function post-procedure as it may have changed, requiring dose adjustment 1

Delayed Resumption Scenarios

Delay DOAC resumption to 24-48 hours post-procedure if: 3

• Ongoing bleeding or surgical contraindication exists 1
• High bleeding risk procedure was performed 3
• Inadequate hemostasis at access site 1, 8
• Start venous thromboprophylaxis (mechanical or pharmacologic) during the delay period based on thrombotic risk 1

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Special Considerations and Common Pitfalls

What NOT to Do

• Do NOT bridge with heparin - this significantly increases bleeding without reducing thrombotic events 1, 3, 4, 5
• Do NOT assume 24 hours is sufficient for all patients - renal function and access site dictate timing 1, 3
• Do NOT use ACT to guide anticoagulation in DOAC patients - it is unreliable 1
• Do NOT routinely measure DOAC levels before elective procedures 4, 5
• Do NOT switch from DOAC to warfarin peri-procedurally - this increases bleeding and thrombotic risk 1

When DOAC Level Testing May Be Useful

• Emergency or urgent procedures (<24 hours) where DOAC levels may still be elevated 5, 2
• Severe renal impairment (CrCl <15 mL/min) where clearance is unpredictable 1
• Consideration of reversal agents in urgent/emergent settings 5, 2
• DOAC levels >50 ng/mL may be considered clinically relevant and necessitate reversal before urgent procedures 2

Antiplatelet Therapy Coordination

• Continue aspirin throughout the peri-procedural period 8
• Administer P2Y12 inhibitor loading dose (clopidogrel 600 mg preferred) if not already on therapy 1, 8
• Post-PCI, follow standard dual antiplatelet therapy duration based on stent type and clinical scenario 1

Fully Anticoagulated Patients (Uninterrupted DOAC)

• While the 2018 EHRA guidelines suggest DOACs should be discontinued before catheterization 1, a small study demonstrated that transradial diagnostic catheterization can be safely performed in fully anticoagulated patients (INR 2.5 ± 0.5) with no access site complications 6
• However, this approach is NOT standard practice and most guidelines recommend interruption as outlined above 1
• If PCI is performed without DOAC interruption, periprocedural anticoagulation dosing remains uncertain 1

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Algorithm Summary

Step 1: Assess Urgency

• Emergency (STEMI/high-risk NSTEMI) → Stop DOAC, proceed immediately 1
• Elective/urgent (can defer) → Calculate CrCl, determine hold duration 1

Step 2: Determine Hold Duration (Elective/Urgent)

• Transradial: 24 hours (most DOACs, CrCl ≥30) 1
• Transfemoral: 48 hours (most DOACs, CrCl ≥30) 1
• Adjust for renal function and specific DOAC (dabigatran requires longer) 1

Step 3: Perform Procedure

• Use standard intraprocedural anticoagulation 1
• Prefer radial access 1, 6

Step 4: Assess for Restart

• Check access site hemostasis 1, 8
• Evaluate bleeding risk factors 1
• Reassess renal function 1

Step 5: Resume DOAC

• Typical: 6-24 hours post-procedure 1, 8
• Delayed: 24-48 hours if high bleeding risk 3
• Adjust dose for renal function 1