What is a reasonable protocol for how long to hold warfarin and/or DOACs before cardiac catheterization? 

Thanks for bringing up this question Dr. @Dr. First Last.

This is one of the most common questions my nurses ask me when scheduling cardiac catheterizations and other procedures.

Here is my answer based on experience and literature. As such, there is no formal study, but the risk of thromboembolism is quite low for a brief interruption of anti-coagulation.

1. We hold all DOACs for 48 hours for cardiac catheterizations. We resume the DOAC therapy the day after the procedure.
2. We hold Warfarin for 72 hours or 3 days for cardiac catheterization. We resume it in the evening on the day of the procedure, provided there are no bleeding issues or concerns.
3. There is no need for bridging except in patients with Mechanical valves (where the decision will...

Our cath lab routine is to hold DOACs for 24 hours, except for Pradaxa which we hold for 48 hours. We do not check INR since studies show it does not reflect coagulation status with DOACs.

Coumadin is held for 3-5 days depending on INR, Goal INR =/< 1.6 procedure day.

For uncomplicated procedures anticoagulation is restarted that evening.

Great question and I will share as an electrophysiologist with some data from interventional cardiologists. Not sure if this moves the needle for being comfortable with more anticoagulation present.

The 2021 SCAI expert consensus for best practices in the cardiac cath lab (Naidu et al., PMID 33909349) recommends operators balance access site bleeding with risk of ischemic or thrombotic events. For femoral access, they recommend INR <1.8 if warfarin is anticoagulant (but note little evidence to support this) and DOAC should be discontinued 24-48 hrs prior depending on operator's concern for bleeding. If low GFR and on DOAC, >48 hrs may be needed for prolonged half-life. For radial access, similar recommendations but data existed but continued...

It is interesting to see the differing practices from the proceduralists.

Not being the one doing the PCI/ablation, etc., I do not make the decision (nor personally carry the risk) but obviously, best practice is paramount to weigh the risk/benefit to favor outcomes.