A Canadian perspective of periprocedural management of patients on oral anticoagulation referred for cardiac catheterization

BACKGROUND: Atrial fibrillation (AF) and coronary artery disease are both prevalent in our aging population, with an estimated 25-30% of patients having both conditions. Approximately 10% of patients referred for coronary angiography and percutaneous coronary intervention (PCI) are on long-term oral anticoagulation. The optimal peri-procedural management of this unique patient population is still unclear. METHODS/RESULTS: We conducted an online national-wide survey of Canadian interventional cardiologists to assess practice patterns across the country. A total of 38 responded representing 23 cardiac catheterization laboratories (53% of all labs in the country). Seventeen percent of responders were cath lab or fellowship directors, while 64% were at academic teaching sites. The majority of centers had 5-10 operators (67%) with an average operator caseload ranging from 200 to 800 angiograms and 150 to 400 PCI per year. Forty two percent of the labs had a protocol for peri-procedure management of patients on therapeutic Warfarin while 53% percent of labs had a protocol for peri-procedure management of patients on a novel oral anticoagulant (NOAC). For labs without a protocol, the practice was similar among the group for both Warfarin (75%) and NOAC (83%). The following table demonstrates peri-operative management of patients on oral anti-coagulation undergoing coronary procedures. The following figure describes the responder's impression on the safety of coronary procedures with continued anti-coagulation. Most angiographers (72%) preferred a radial approach in anti-coagulated patients, while 33% preferred using a bare-metal stent. For patients on Warfarin, the preferred anticoagulation is IV Heparin (72%) while the rest chose Bivalirudin (20%) and8%gave no additional anticoagulation. If a Heparin bolus was given,56%would give a reduced dose. For a patient anti-coagulated with NOAC, prior to PCI, 72% preferred IV Heparin, 14% preferred Bivalirudin and 14% gave no additional anticoagulation. If a Heparin bolus was given, 53% would give a reduced dose. CONCLUSIONS: This Canadian survey highlights the varied practice in peri-procedure management among cardiac catheterization laboratories for patients on oral anticoagulation. Despite studies demonstrating the safety of uninterrupted anticoagulation for coronary angiography and intervention, anticoagulation interruption is by far the most common approach to peri-procedural management of this patient group.More research and education is needed in this area. (Figure Presented).