Precision Medicine for Anticoagulation Strategies in the Cath Lab: Part 1

Intraprocedural anticoagulation in the cardiac catheterization laboratory is essential to prevent thrombus formation on catheters, guidewires, and stents while minimizing bleeding risk. This review summarizes contemporary evidence and guideline recommendations for anticoagulation strategies during diagnostic catheterization and percutaneous coronary intervention (PCI).

Unfractionated heparin (UFH) remains the standard intraprocedural agent, typically administered as a 50-100 U/kg intravenous bolus, and is routinely used during transradial access to prevent radial artery occlusion. Low-molecular-weight heparin (LMWH), particularly enoxaparin, provides more predictable factor Xa-mediated anticoagulation and is an alternative option for patients undergoing PCI in the settings of stable coronary artery disease (CAD), non-ST-segment elevation acute coronary syndrome (NSTE-ACS), and ST-segment elevation myocardial infarction (STEMI). Bivalirudin, a direct thrombin inhibitor, offers consistent anticoagulation independent of plasma cofactors and, particularly in STEMI, can be combined with a 2-4 h post-PCI infusion to reduce early stent thrombosis. Bivalirudin is an accepted alternative to UFH in both stable CAD and ACS, and is a preferred alternative to UFH to reduce mortality and major bleeding in STEMI (Class I recommendation), as well as in patients with heparin-induced thrombocytopenia or those at high bleeding risk. Fondaparinux has been associated with an increased risk of catheter-related thrombosis and therefore should not be used as a stand-alone intraprocedural anticoagulant during PCI. In PCI, contemporary randomized trials and guideline recommendations support UFH as standard therapy, with enoxaparin and bivalirudin as effective alternatives depending on clinical presentation and bleeding risk. Further studies are needed to refine anticoagulation strategies based on individualized risk factors and procedural context in contemporary PCI.