Antiplatelet Management for Heart Catheterization
Yes, patients should continue both Brilinta (ticagrelor) and aspirin (Imbur) through diagnostic heart catheterization without interruption, as the thrombotic risk of discontinuation substantially outweighs any bleeding risk during diagnostic procedures. 1
For Diagnostic Catheterization Only
Continue all antiplatelet therapy without interruption. The decision about whether to proceed with PCI can be made after visualizing the coronary anatomy, and if PCI is performed, additional loading can be administered in the catheterization laboratory if needed 1.
Key Management Points:
- Aspirin should never be discontinued and must be continued through the procedure 2
- Ticagrelor (Brilinta) should be continued through diagnostic catheterization 1
- The thrombotic risk in patients on dual antiplatelet therapy (especially those with prior ACS or stents) far exceeds the minimal bleeding risk of diagnostic catheterization 1
Critical Exception: If CABG Cannot Be Excluded
Only if CABG is being seriously considered and catheterization is planned within 24-36 hours, it may be reasonable to withhold ticagrelor until coronary anatomy excludes the need for urgent CABG, but aspirin must still be continued 1, 2.
However, this exception has important caveats:
- This applies only to stable patients where catheterization can safely wait 2
- For unstable patients or known ACS, ticagrelor should be administered immediately regardless of potential CABG, as the ischemic benefit outweighs bleeding risk 2
- Aspirin is never withheld even when considering CABG 2
If CABG Becomes Necessary After Catheterization
Should coronary anatomy reveal the need for CABG:
- Ticagrelor must be withheld for at least 5 days before elective CABG 3
- Preferably wait 7 days if the clinical situation allows 2
- Recent evidence suggests waiting at least 3 days after ticagrelor discontinuation significantly reduces severe bleeding risk (16.0% bleeding at 0-2 days vs 2.7% at ≥3 days) 4
- Aspirin should generally be continued perioperatively for CABG, as it reduces cardiovascular events and mortality 1
Special Considerations for Patients with Coronary Stents
This is critically important: If your patient has a coronary stent, particularly a drug-eluting stent placed within the past year:
- Elective surgery should be deferred for 6 weeks after bare-metal stent and 6 months after drug-eluting stent 1
- If surgery must occur within these timeframes, continue antiplatelet therapy perioperatively rather than stopping it 1
- The risk of stent thrombosis with premature antiplatelet discontinuation carries a case-fatality rate of approximately 50% 1
- Cardiology consultation is essential before any antiplatelet interruption in stented patients 2
Resumption After Any Necessary Interruption
If ticagrelor must be temporarily discontinued for CABG:
- Restart as soon as possible after the procedure 1
- Resume within 12-24 hours once hemostasis is achieved 1
- Aspirin should be resumed within 24 hours when adequate hemostasis has been achieved 1
Common Pitfall to Avoid
Do not discontinue dual antiplatelet therapy for diagnostic catheterization. The most common error is unnecessarily stopping antiplatelet agents before diagnostic procedures when continuation is both safe and strongly recommended 1, 2. The bleeding risk during diagnostic catheterization is minimal, while the thrombotic risk of discontinuation—especially in patients with prior ACS or stents—can be catastrophic 1.