Should I hold Xarelto (rivaroxaban) the night before a left‑ or right‑heart catheterisation in an adult with normal renal function and no high‑risk thrombotic features?

Holding Xarelto Before Left or Right Heart Catheterization

For left or right heart catheterization, hold Xarelto (rivaroxaban) the night before the procedure—specifically, skip the dose 24 hours prior to the procedure in patients with normal renal function. 1, 2

Procedural Bleeding Risk Classification

Heart catheterization (LHC/RHC) is classified as a high-risk bleeding procedure due to:

• Vascular access requiring large-bore arterial and/or venous sheaths 1
• Risk of cardiac perforation during catheter manipulation 1
• Potential for retroperitoneal bleeding from femoral access 1
• Need for complete hemostasis at puncture sites 1

Specific Timing for Rivaroxaban Interruption

Standard approach for normal renal function (CrCl ≥50 mL/min):

• Hold rivaroxaban for 24 hours before the procedure (skip 1 dose) 1, 2
• This corresponds to approximately 3 half-lives, leaving minimal residual anticoagulant effect 1
• The FDA label confirms stopping "at least 24 hours before the procedure to reduce the risk of bleeding" 2

For impaired renal function (CrCl 30-50 mL/min):

• Hold rivaroxaban for 48-72 hours before the procedure (skip 2-3 doses) 1
• Rivaroxaban has 33% renal elimination, requiring longer interruption with reduced kidney function 1, 3

Why This Differs from Lower-Risk Procedures

The 2021 BSG/ESGE guidelines distinguish between low-risk procedures (where only the morning dose is omitted) and high-risk procedures (requiring 3 days of interruption for DOACs) 1. However, cardiac catheterization falls into an intermediate category where:

• The 2012 Blood guidelines specifically recommend 2 days preoperative interruption for rivaroxaban before major surgery with spinal anesthesia (similar vascular access risk) 1
• The 2014 AHA/ACC/HRS guidelines note that in the ROCKET AF trial, rivaroxaban was held for 2 days before elective surgery 1
• The FDA label mandates "at least 24 hours" for any procedure with bleeding risk 2

Bridging Anticoagulation

Do not use bridging anticoagulation (heparin or LMWH) when interrupting rivaroxaban 1, 3. The rapid offset and onset of rivaroxaban make bridging unnecessary and potentially increase bleeding risk 1.

Postprocedural Resumption

Resume rivaroxaban 24-48 hours after the procedure once adequate hemostasis is established at vascular access sites 1, 2:

• For uncomplicated cases with secure hemostasis: resume at 24 hours 1
• For cases with larger sheaths or access site concerns: wait 48-72 hours 1
• Therapeutic anticoagulation is achieved within 2-4 hours of rivaroxaban administration 1, 3

Critical Caveats

Verify renal function before the procedure 1:

• Calculate CrCl or eGFR to determine appropriate interruption duration 1
• If renal function is rapidly deteriorating, consult hematology 1

Consider thrombotic risk 1:

• For patients at very high thrombotic risk (mechanical valves, recent stroke, CHA₂DS₂-VASc ≥4), the 24-hour interruption still applies, but ensure prompt resumption 1
• The short interruption period minimizes time without anticoagulation 1

Avoid prophylactic reversal agents 4, 5:

• Do not give prothrombin complex concentrate (PCC) or other hemostatic agents prophylactically before the procedure 4, 5
• Reserve reversal agents only for active life-threatening bleeding 5, 6