Preprocedural Evaluation



Preprocedural Evaluation


Bethany A. Austin



Cardiac catheterization is an invaluable tool for both diagnostic and therapeutic purposes, with between 2 and 3 million procedures performed annually in the United States. Due to the inherent risks associated with this invasive procedure, angiographers must be well versed in the indications, contraindications, and potential complications associated with this procedure. Thorough preprocedural evaluation facilitates appropriate selection of candidates for catheterization and identification of those at highest risk for complications.


Clinical Evaluation

Careful inquiry into a patient’s clinical presentation is an essential component of the precatheterization evaluation. In addition to establishing the indication for catheterization, the clinical syndrome guides the selection of techniques employed during catheterization, including coronary angiography, hemodynamic measurements, left ventriculography, aortography, cerebral angiography, peripheral angiography, renal angiography, right heart catheterization, biopsy, and provocative chemical challenge.

Concomitant medical conditions should be identified and relevant comorbidities addressed prior to catheterization (Table 1-1). For example, severe thrombocytopenia or coagulopathy may render the patient ineligible for catheterization. In those with a prior history of heparin-induced thrombocytopenia, heparin-free solutions and flushes should be prepared. Alternate forms of anticoagulation, such as direct thrombin inhibitors, may be preferable for percutaneous intervention. In patients with chronic kidney disease (CKD), renal function should be optimized prior to catheterization (see Troubleshooting and Table 1-6).

Patients with severe lower extremity arterial disease may require catheterization via the brachial or radial artery. A history of an aortic aneurysm of significant size or prior aortic dissection may also favor
brachial or radial artery access. Any history of claudication in conjunction with the peripheral pulse exam should be taken into account when selecting the arterial access site.








Table 1-1 Relevant Historical Elements







  1. Prior cardiac catheterizations and/or cardiac surgeries



  2. Results of noninvasive cardiac imaging (echo, stress test, ECG)



  3. Comorbid medical conditions




    1. Chronic kidney disease



    2. Diabetes mellitus



    3. Peripheral vascular disease



    4. Aortic aneurysm/dissection



    5. Valvular heart disease



    6. Thrombocytopenia/heparin-induced thrombocytopenia



    7. Coagulopathy



    8. Anemia



    9. Cerebrovascular disease



    10. Hypertension



    11. Pulmonary disease



    12. Liver disease



    13. Contrast allergy


In patients with known pre-existing coronary artery disease, detailed knowledge of all prior catheterizations, percutaneous interventions, and cardiac surgeries is imperative. If possible, films of prior catheterizations should be reviewed for comparison. The angiographic location of prior bypass graft origins should be noted, as should any unusual catheters previously required. Knowledge of prior peripheral vascular interventions and surgeries is also useful in planning access.

Medication allergies should be documented prior to the procedure. In particular, patients with a history of contrast media allergy require special consideration (see Troubleshooting). Latex allergy is not a contraindication to cardiac catheterization; however, the catheterization laboratory should be notified of the allergy and be prepared to use only latex-free equipment for the case. Particular attention should also be paid to allergies to medications that are commonly used during the procedure, such as benzodiazepines and opiates.

A focused physical exam is a prerequisite for cardiac catheterization. Specifically, there should be an evaluation of any stigmata of congestive heart failure (CHF) such as rales, jugular venous distension, an S3, or
peripheral edema. Auscultation of any murmurs, particularly those that suggest aortic stenosis or mitral regurgitation, should be noted. A careful examination of peripheral pulses and search for arterial bruits will influence the choice of arterial access site and serve as a helpful comparison when assessing for postprocedural vascular complications.

Standard laboratory evaluation includes electrolytes, blood urea nitrogen, serum creatinine, blood glucose, and complete blood count. A coagulation panel is indicated in any patient on anticoagulant medication or who is at risk for significant hepatic dysfunction. These laboratory tests should be current (i.e., within 1 month of the procedure). Similarly, a current electrocardiogram should be assessed. Evidence of ischemia, prior myocardial infarction (MI), rhythm disturbances, and chamber enlargement/hypertrophy should be noted. The baseline electrocardiogram also provides a comparison for any periprocedural changes. If a prior echocardiogram is available, preprocedural knowledge of left ventricular systolic or diastolic dysfunction, significant valvular disease, and aortic abnormalities is often helpful. Similarly, if a prior stress test is available, one should be familiar with areas of ischemia and scar.


Indications

The decision to proceed with diagnostic cardiac catheterization is based on a careful assessment of the risk-benefit ratio for the procedure (Table 1-2). The most current guidelines for diagnostic coronary angiography, reported by a joint Task Force of the American College of Cardiology and the American Heart Association (ACC/AHA), divide the indications for coronary angiography into three classes. Class I indications are conditions for which there is evidence and/or general agreement that the procedure is useful and effective. Class II indications are conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of performing the procedure. Class III indications are conditions for which there is evidence and/or general agreement that the procedure is not useful/effective and that in some cases may be harmful.

Cardiac catheterization is a powerful tool for risk stratification during acute MI and for facilitating revascularization. Emergent coronary angiography with the intent to perform primary percutaneous coronary intervention is most applicable to patients presenting within 12 hours of an acute ST elevation or new left bundle branch block (LBBB) MI. This strategy can also be applied to patients with non-ST elevation MI who have persistent or recurrent symptoms despite optimal medical therapy or high-risk features which include elevated troponin, new ST depression, signs/symptoms of CHF, hemodynamic or electrical instability, and prior revascularization. Ideally, door-to-balloon time in patients with ST elevation MI should be within 90 minutes. Urgent angiography should also be performed in those patients younger than 75 years with ST elevation MI complicated by cardiogenic shock developing within 36 hours of MI who are candidates for revascularization. It is reasonable to include patient older than 75 years of age who have good functional status and who are both suitable and agreeable to revascularization. Patients with persistent chest pain or ST elevation after fibrinolytic therapy should also have urgent angiography with the intent to perform primary percutaneous intervention. Additionally, patients who are successfully resuscitated from sudden cardiac death (without a readily identifiable cause) have a high probability of underlying coronary disease and should undergo cardiac catheterization.











Table 1-2 Indications for Coronary Angiography


































































































































































































Class Ia,b


Unstable Coronary Syndromes

Unstable angina/ACS refractory to medical therapy or recurrent symptoms after initial medical therapy

Unstable angina/ACS with high-risk indicators

Unstable angina/ACS initially at low short-term risk, with subsequent high-risk noninvasive testing

Prinzmetal angina with ST elevation

Suspected acute or subacute stent thrombosis after PCI


Angina

High-risk noninvasive testing

CCS class III or IV angina on medical therapy

Recurrent angina 9 months after PCI


Acute Myocardial Infarction

Intended PCI in acute ST elevation or new LBBB MI


Within 12 hours of symptom onset


Ischemic symptoms persisting after 12 hours of symptom onset


Cardiogenic shock in candidates for revascularization


Persistent hemodynamic or electrical instability

Angiography in non-ST elevation MI


As part of an early invasive strategy in high-risk patients (+ troponin, ST changes, CHF, hemodynamic/electrical instability, recent revascularization)


Persistent or recurrent symptomatic ischemia with or without associated ECG changes despite anti-ischemic therapy


Resting ischemia or ischemia provoked by minimal exertion following infarction

Prior to surgical repair of a mechanical complication of MI in a sufficiently stable patient


Perioperative Risk Stratification for Noncardiac Surgery

High-risk noninvasive testing

Unstable angina or angina unresponsive to medical therapy

Equivocal noninvasive test result in patient with high clinical risk undergoing high-risk surgery


Congestive Heart Failure

Systolic dysfunction associated with angina, regional wall motion abnormalities, or ischemia on noninvasive testing


Other Conditions

Valvular surgery in patients with angina, significant risk factor(s) for CAD, or abnormal noninvasive testing

Valvular surgery in men 35 or older, any postmenopausal woman, and premenopausal women 35 or older with cardiac risk factors

Correction of congenital heart disease in patients with angina, high-risk noninvasive testing, form of congenital heart disease frequently associated with coronary artery anomalies, or in those with known coronary anomalies

After successful resuscitation from sudden cardiac death, sustained monomorphic ventricular tachycardia, or nonsustained polymorphic ventricular tachycardia

Infective endocarditis with evidence of coronary embolization

Diseases of the aorta necessitating knowledge of concomitant coronary disease

Hypertrophic cardiomyopathy with angina


Class IIac


Angina

CCS class I or II, EF <45%, and abnormal but not high-risk noninvasive testing

Patients with an uncertain diagnosis after noninvasive testing in whom the benefits of the procedure outweigh the risk

Patient who cannot be risk stratified by other means

Patients in whom nonatherosclerotic causes such as anomalous coronary artery, radiation vasculopathy, coronary dissection, etc. are suspected

Recurrent angina/symptomatic ischemia within 12 months of CABG

Recurrent angina poorly controlled with medical therapy after revascularization

Patients with CHF who have chest pain, have not had evaluation of their coronary anatomy, and do not have contraindications to revascularization


Acute Myocardial Infarction

MI suspected to have occurred by a mechanism other than thrombotic occlusion of atherosclerotic plaque (coronary embolism, arteritis, trauma, coronary spasm)

Failed thrombolysis with planned rescue PCI

Post MI with LVEF <40%, CHF, or malignant arrhythmias

CHF during acute episode with subsequent demonstration of LVEF >40%

Patients with recurrent ACS despite therapy without high-risk features


Perioperative Risk Stratification for Noncardiac Surgery

Planned vascular surgery with multiple intermediate clinical risk factors

Moderate-large region of ischemia on stress test without high-risk features or decreased EF

Equivocal noninvasive testing in patient with intermediate clinical risk undergoing high-risk surgery

Urgent noncardiac surgery while recovering from an acute MI


Other Conditions

Systolic LV dysfunction with unexplained cause after noninvasive testing

Episodic CHF with normal LV systolic function with suspicion for ischemiamediated LV dysfunction

Before corrective surgery for congenital heart disease in patients whose risk factors increase likelihood of coronary disease

Recent blunt chest trauma and suspicion for acute MI

Before surgery for aortic dissection/aneurysm

Periodic follow-up after cardiac transplantation or for prospective immediate cardiac transplant donors

Asymptomatic patients with Kawasaki disease and coronary artery aneurysms on echocardiography


a ACC/AHA Guidelines adapted from Scanlon JP, Faxon DP, Audet AM, et al. ACC/AHA guidelines for coronary angiography: executive summary and recommendations. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Coronary Angiography). Circulation. 1999;99:2345-2357; and Libby P, Bonow RO, Mann DL, et al. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Philadelphia: W.B. Saunders Company; 2007.

b Conditions for which there is evidence and/or general agreement that this procedure is indicated.

c Conditions for which indications are controversial, but the weight of the evidence is supportive.


ACS, acute coronary syndrome; CABG, coronary artery bypass graft, CAD, coronary artery disease, CCS, Canadian Cardiovascular Society, CHF, congestive heart failure, ECG, electrocardiogram, LBBB, left bundle branch block; LVEF, left ventricular ejection fraction, MI, myocardial infarction, PCI, percutaneous coronary intervention.

Only gold members can continue reading. Log In or Register to continue

Related posts:

  1. Setting up the Lab
  2. Native Coronary Angiography
  3. Approach to the High-Risk Patient
  4. Hemostatic Devices

Stay updated, free articles. Join our Telegram channel
Tags:
Jul 8, 2016 | Posted by in CARDIAC SURGERY | Comments Off on Preprocedural Evaluation

Full access? Get Clinical Tree
Get Clinical Tree app for offline access