Should anticoagulation be held prior to cardiac catheterization?

Management of Anticoagulation Prior to Cardiac Catheterization

Oral anticoagulation can be continued at modified doses in the majority of patients undergoing cardiac catheterization, particularly when using radial artery access. 1

Standard Approach for Most Patients

For routine diagnostic and interventional cardiac catheterization, anticoagulation does not need to be held in most cases. 1 The key considerations are:

Radial Access (Preferred Approach)

• Radial artery access allows continuation of oral anticoagulation without interruption, as this approach minimizes bleeding risk even in fully anticoagulated patients 1, 2
• Patients can safely undergo left and right heart catheterization via radial artery and antecubital vein while fully anticoagulated (INR 2.5 ± 0.5) with no access site complications 2
• Radial access is recommended when possible given the significantly lower bleeding risk compared to femoral access 1

Femoral Access

• If femoral access is necessary, vascular closure devices should be used to minimize bleeding risk 1
• Real-world data shows that most cardiac catheterizations are still performed via femoral access with OAC interruption, though this may not be optimal practice 3

Specific Clinical Scenarios Requiring Anticoagulation Interruption

Anticoagulation MUST be stopped for high-risk procedures including: 1

High-Risk Interventions

• Transseptal catheterization (for valvular interventions or left atrial procedures) 1
• Direct left ventricular puncture 1
• Pericardial drainage procedures 1

For these procedures, oral anticoagulants should be stopped and bridging anticoagulation administered using the protocol below 1

Bridging Protocol When Interruption is Required

For Warfarin (VKA)

• Stop warfarin 5 days before the procedure to allow INR to normalize 1
• Begin bridging with UFH (intravenous preferred) or LMWH when INR falls below 2.0 1
• UFH should be discontinued 4-6 hours before the procedure 1
• LMWH should be discontinued >12 hours before the procedure 1
• Resume effective anticoagulation as soon as possible after the procedure according to bleeding risk 1

For DOACs (Apixaban, Rivaroxaban, Dabigatran, Edoxaban)

• Stop DOAC at least 48 hours prior to procedures with moderate or high bleeding risk 4
• Stop DOAC at least 24 hours prior to procedures with low bleeding risk 4
• Bridging anticoagulation is NOT generally required for DOACs due to their short half-life and similar pharmacokinetic properties to LMWH 1, 4
• Restart DOAC as soon as adequate hemostasis is established 4

Intraprocedural Anticoagulation Management

All patients undergoing cardiac catheterization with arterial access require procedural anticoagulation: 1, 5

Standard Heparin Protocol

• Initial UFH bolus: 100 U/kg (maximum 5000 U) at the start of the procedure 1, 5
• Target ACT >200 seconds for standard procedures 1, 5
• Target ACT 250-300 seconds for high thrombotic risk procedures 1, 5
• Monitor ACT 1 hour after bolus, then every 30 minutes for prolonged procedures 1, 5
• Additional heparin 50-100 U/kg as needed to maintain target ACT 1, 5

Alternative Anticoagulants

• Bivalirudin, LMWH, or UFH are all acceptable intraprocedural options 1
• For patients with heparin-induced thrombocytopenia (HIT), bivalirudin is the preferred alternative 5

Special Populations

Mechanical Heart Valves

• These patients are at highest risk for thromboembolism and benefit most from uninterrupted anticoagulation 6
• If interruption is absolutely necessary, bridging with UFH (the only approved heparin for mechanical valves) is mandatory 1
• Intravenous UFH is strongly preferred over subcutaneous administration 1

Atrial Fibrillation Patients

• Real-world data shows OAC is interrupted in 93.8% of AF patients undergoing catheterization, though this may not be necessary for most cases 3
• Nearly 40% of patients fail to restart OAC post-procedure, exposing them to stroke risk - this is a critical pitfall to avoid 3
• Patients on warfarin have higher rates of major bleeding (43.3 vs 12.9 events/100 patient-years) and stroke (4.9 vs 1.9 events/100 patient-years) compared to DOAC patients 3

Pediatric Patients

• Uninterrupted anticoagulation during cardiac catheterization is safe in pediatric patients with only 1.4% bleeding-related complications 6
• Median time to hemostasis is 18 minutes (range 5-76 minutes) 6
• This approach is particularly beneficial for pediatric patients with mechanical valves, avoiding bridging complications 6

Critical Pitfalls to Avoid

Common Errors

• Using fixed-dose heparin without weight-based dosing leads to significant over or under-anticoagulation 1, 5
• Failing to monitor ACT during prolonged procedures results in inconsistent anticoagulation 5
• Using LMWH for bridging in patients with mechanical valves is off-label and UFH remains the only approved option 1
• Delayed hemorrhagic complications can occur 3-11 days post-procedure when using enoxaparin bridging, particularly with femoral access 7

Post-Procedure Management

• Failure to restart anticoagulation exposes patients to significant stroke risk - this occurs in nearly 40% of real-world cases 3
• Carefully evaluate bleeding risk and access site hemostasis before restarting anticoagulation 1
• For patients with subtherapeutic INR during routine monitoring, bridging with LMWH in an outpatient setting is indicated until therapeutic INR is reached 1