What medications should be discontinued prior to cardiac catheterization (cardiac cath)?

From the Guidelines

Before cardiac catheterization, anticoagulants like warfarin should be stopped 3-5 days before the procedure, while direct oral anticoagulants (DOACs) such as apixaban, rivaroxaban, and dabigatran should be held for 1-2 days before, depending on the drug and renal function, as recommended by the 2024 ESC guidelines for the management of chronic coronary syndromes 1.

Medications to Stop Before Cardiac Catheterization

The following medications may need to be temporarily discontinued before cardiac catheterization:

• Anticoagulants:
  • Warfarin: stop 3-5 days before the procedure, with INR checked to ensure it's below 1.8
  • Direct oral anticoagulants (DOACs) such as apixaban, rivaroxaban, and dabigatran: hold for 1-2 days before the procedure, depending on the drug and renal function, as recommended by the 2024 ESC guidelines for the management of chronic coronary syndromes 1
• Antiplatelet medications:
  • Clopidogrel: stop ≥5 days before the procedure
  • Ticagrelor: stop ≥3 days before the procedure
  • Prasugrel: stop ≥7 days before the procedure
• Other medications:
  • Metformin-containing diabetes medications: stop 48 hours before the procedure due to the risk of lactic acidosis when combined with contrast dye, especially in patients with kidney dysfunction
  • Non-steroidal anti-inflammatory drugs (NSAIDs): discontinue 24-48 hours before the procedure to reduce bleeding risk

Recommendations for Specific Medications

• Aspirin: usually continued, but may be stopped or adjusted based on individual patient factors and the specific type of cardiac catheterization planned
• Antihypertensives, including beta-blockers, ACE inhibitors, and calcium channel blockers: typically continued through the morning of the procedure with a small sip of water

Important Considerations

• The timing of medication discontinuation may vary based on individual patient factors, the specific type of cardiac catheterization planned, and the physician's preference
• Patients should always follow their cardiologist's specific instructions regarding medication management before cardiac catheterization
• The 2024 ESC guidelines for the management of chronic coronary syndromes provide the most up-to-date recommendations for medication management before cardiac catheterization 1

From the FDA Drug Label

2.8 Discontinuation for Surgery and Other Interventions If possible, discontinue dabigatran etexilate capsules in adults 1 to 2 days (CrCl ≥50 mL/min) or 3 to 5 days (CrCl <50 mL/min) before invasive or surgical procedures because of the increased risk of bleeding Consider longer times for patients undergoing major surgery, spinal puncture, or placement of a spinal or epidural catheter or port, in whom complete hemostasis may be required

Medications to Stop Before Cardiac Catheterization:

• Dabigatran etexilate capsules should be discontinued 1 to 2 days (CrCl ≥50 mL/min) or 3 to 5 days (CrCl <50 mL/min) before cardiac catheterization to minimize the risk of bleeding.
• The exact duration of discontinuation may vary depending on the patient's renal function and the type of procedure being performed.
• It is essential to weigh the risk of bleeding against the urgency of the intervention and consider alternative anticoagulation coverage if necessary 2.

From the Research

Medications to Stop Before Cardiac Catheterization

• The decision to stop medications before cardiac catheterization depends on the individual patient's risk of thrombosis and bleeding, as well as the type of medication they are taking 3.
• Patients taking oral anticoagulants such as warfarin, dabigatran, rivaroxaban, or apixaban, or antiplatelet agents such as aspirin, clopidogrel, prasugrel, or ticagrelor, may need to interrupt their therapy before cardiac catheterization 3.
• For patients with a low bleeding risk, oral anticoagulation/antiplatelet therapy can be continued or reduced in intensity 3.
• In patients with an intermediate or high bleeding risk, along with a low thrombosis risk, a temporary interruption of the anticoagulation/antiplatelet therapy is feasible 3.
• Patients treated with new oral anticoagulants such as dabigatran, rivaroxaban, or apixaban may need to temporarily interrupt their anticoagulation depending on the individual drug half-life and their renal function 3.
• Bridging therapy with heparin prior to intervention is not necessary with the new oral anticoagulants 3.
• The safety of apixaban and rivaroxaban compared to warfarin after cardiac surgery has been evaluated, and the results suggest that apixaban and rivaroxaban demonstrate similar safety when compared to a matched cohort of warfarin patients 4.
• Evidence-based practices in the cardiac catheterization laboratory have been reviewed, highlighting common preprocedure, intraprocedure, and postprocedure catheterization laboratory practices where evidence has accumulated over the past few decades to support or discount traditionally held practices 5.
• The characteristics of patients undergoing cardiac catheterization before noncardiac surgery have been described, and the results highlight management patterns in this population and the need for greater evidence-based guidelines and practices 6.
• A meta-analysis of the efficacy and safety of rivaroxaban compared with warfarin or dabigatran in patients undergoing catheter ablation for atrial fibrillation has been conducted, and the results suggest that patients treated with rivaroxaban during periprocedural catheter ablation have similar rates of thromboembolic events and major hemorrhage 7.