When should anti-coagulation therapy be held in patients with a high risk of bleeding or those undergoing invasive procedures, particularly in those with a history of atrial fibrillation or venous thromboembolism?

Indications to Hold Anticoagulation

Anticoagulation should be held for elective invasive procedures based on bleeding risk and renal function, with DOACs stopped 24-48 hours before low-bleeding-risk procedures and warfarin held until INR ≤2.0, while emergency procedures require immediate cessation without delay. 1

Emergency Procedures

For ST-elevation myocardial infarction or high-risk non-ST-elevation myocardial infarction, stop anticoagulation immediately and proceed with PCI without delay. 1, 2 Activated clotting time is not reliable for assessing anticoagulation status in patients taking DOACs during emergency procedures. 1, 2

Elective Procedures: DOAC Management

Transradial Access Procedures

For patients with creatinine clearance ≥30 mL/min, hold DOACs (apixaban, rivaroxaban, edoxaban) for 24 hours before the procedure. 1

For patients with creatinine clearance 15-29 mL/min, extend the holding period to 36 hours. 1

For patients with creatinine clearance <15 mL/min, hold for 48 hours or guide duration by agent-specific anti-Xa levels. 1

Transfemoral Access Procedures

For patients with creatinine clearance ≥30 mL/min, hold DOACs for 48 hours before the procedure. 1, 2

For patients with creatinine clearance <29 mL/min, extend to 72 hours or guide by anti-Xa levels. 1

Dabigatran-Specific Timing (Transradial)

• CrCl ≥80 mL/min: hold 24 hours 1
• CrCl 50-79 mL/min: hold 36 hours 1
• CrCl 30-49 mL/min: hold 48 hours 1
• CrCl 15-29 mL/min: hold 72 hours 1
• CrCl <15 mL/min: hold 96 hours or guide by dilute thrombin time 1

Dabigatran-Specific Timing (Transfemoral)

• CrCl >80 mL/min: hold 48 hours 1
• CrCl 50-79 mL/min: hold 72 hours 1
• CrCl 30-49 mL/min: hold 96 hours 1
• CrCl 15-29 mL/min: hold 120 hours 1
• CrCl <15 mL/min: guide by dilute thrombin time 1

Elective Procedures: Warfarin Management

Hold warfarin and defer elective PCI until INR ≤2.0 (some centers use ≤1.5 as threshold). 1 The specific threshold may vary based on vascular access site choice (radial versus femoral). 1

Post-Procedure Resumption

Timing of Anticoagulation Restart

Resume anticoagulation within 24 hours after uncomplicated procedures in most patients, potentially as early as the evening of the procedure day. 1, 2 This decision requires collaboration with the interventional cardiologist and careful assessment of hemostasis at the access site. 1

For patients at low bleeding risk, parenteral anticoagulation can be considered within 24 hours post-procedure. 1

For patients at high bleeding risk, delay parenteral anticoagulation to 48-72 hours post-procedure. 1, 2

Post-Procedure Assessment Factors

Before restarting anticoagulation, evaluate: 1

• Adequacy of hemostasis at the access site 1
• History of recent bleeding 1
• Body habitus (particularly obese patients with transfemoral access) 1
• Platelet abnormalities (qualitative or quantitative) 1
• Coagulation study abnormalities 1
• Post-procedure renal function changes requiring dose adjustment 1, 2

Critical Contraindications to Bridging

Do not use bridging anticoagulation with heparin or LMWH for DOAC patients, as bridging significantly increases bleeding risk without reducing thrombotic events. 1, 2 This applies particularly to patients on DOACs given their similar pharmacokinetic properties to LMWH. 1

For warfarin patients post-PCI, only a small subset with high thromboembolic risk should receive bridging with parenteral anticoagulation until INR reaches therapeutic range. 1

Special Clinical Scenarios

Recent Stroke or TIA

For patients with recent cerebrovascular accident requiring anticoagulation for VTE, hold antiplatelet therapy and initiate anticoagulation alone (DOAC preferred) when safe from hemorrhagic transformation risk, typically 2-14 days following the acute event. 1

For TIA patients (no infarct or hemorrhage on imaging), anticoagulation can typically be initiated immediately. 1

Recent Carotid Procedures

After carotid endarterectomy, hold antiplatelet therapy and start anticoagulation when safe from post-operative bleeding risk, typically 3-14 days after surgery. 1

Active Major Bleeding

When major bleeding occurs, initiate appropriate measures to control bleeding and consider reversal agents to stabilize the patient. 1 Anticoagulation should remain held until bleeding is controlled and hemostasis is secure. 3

Common Pitfalls

The most critical error is continuing anticoagulation at full therapeutic doses through high-bleeding-risk procedures without appropriate holding periods based on renal function. 1

Another common mistake is using bridging therapy for DOAC patients, which increases bleeding without benefit. 1, 2

Failing to reassess renal function post-procedure can lead to inappropriate dosing when anticoagulation is resumed, as contrast-induced nephropathy or acute kidney injury may have occurred. 1, 2