Anticoagulation Management in Cardiac Catheterization

Introduction to Anticoagulation

For most patients undergoing cardiac catheterization, unfractionated heparin (UFH) should be discontinued immediately after the procedure without the need for post-procedural anticoagulation, unless specific risk factors or interventions warrant continued therapy, as recommended by the European Society of Cardiology 1
The American Heart Association recommends an initial UFH bolus of 100 U/kg (maximum 5000 U) for cardiac catheterization procedures, and additional 50-100 U/kg heparin should be administered to maintain activated clotting time (ACT) >200 seconds, with a target ACT of 250-300 seconds for high-risk thrombotic procedures, according to the American College of Cardiology 2

For patients with a right-to-left shunt, interventional procedure, or expected prolonged procedure, a UFH bolus of 100 U/kg is reasonable, as suggested by the American Heart Association 2
Routine anticoagulation may not be necessary for diagnostic right-heart catheterization, unless specific risk factors are present, as stated by the American College of Cardiology 2
For patients requiring chronic anticoagulation, such as those with atrial fibrillation or prosthetic valves, anticoagulation should be resumed as soon as hemostasis is adequate, typically within 24-48 hours, according to the European Society of Cardiology 1

For femoral artery thrombosis or pulse loss after catheterization, continue intravenous UFH for 24-48 hours and consider systemic thrombolytic therapy if pulse remains absent and limb perfusion is compromised, as recommended by the American College of Cardiology 2
Bivalirudin may be considered for patients at high risk of bleeding as an alternative to UFH, according to the European Society of Cardiology 1

For pediatric patients, UFH dosing should be carefully monitored as fixed-dose regimens may result in significant over or under-coagulation, as suggested by the American Heart Association 2
Anticoagulant doses should be adjusted based on patient weight and renal function, according to the European Society of Cardiology 1
Formally assess and document bleeding risk in every patient, as recommended by the European Society of Cardiology 1

While low molecular weight heparin (LMWH) may be considered for procedural thromboprophylaxis, it offers no practical advantages over UFH during cardiac catheterization, as stated by the American College of Cardiology 2
Aspirin alone is not recommended for procedural thromboprophylaxis, according to the American College of Cardiology 2
Patients should be started on dual antiplatelet therapy (DAPT) with aspirin plus a P2Y12 inhibitor after cardiac catheterization with stent placement, with the duration determined by stent type and bleeding risk, as recommended by the American Heart Association 3
The following DAPT regimens are recommended:
Loading doses for DAPT include:
DAPT duration should be adjusted based on bleeding risk:
No routine antiplatelet therapy is required after diagnostic cardiac catheterization without intervention, as stated by the American Heart Association 2
For patients with indications for chronic anticoagulation, aspirin 75-81 mg daily should be continued, and anticoagulation should be resumed as soon as hemostasis is adequate, typically within 24-48 hours, according to the American College of Cardiology 4, 6