Cardiac catheterization pre-procedure evaluation resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Yazan Daaboul, M.D.; Turky Alkathery, M.D. [2]

Cardiac catheterization pre-procedure evaluation resident survival guide Microchapters
Overview
Classification
Pre-procedure Evaluation
Do's
Don'ts

Overview

Cardiac catheterization is an endovascular procedure that aims to study cardiac function and anatomy, as well as to diagnose and treat acute cardiovascular diseases and evaluate surgical candidates. Cardiac catheterization may be either diagnostic (no intervention) or therapeutic (percutaneous coronary intervention or PCI). However, it may also be classified as coronary angiography (assess patency of coronary arteries), left heart catheterization (to assess blood flow, anatomy, and pressures in left heart chambers and to evaluate the anatomy and function of the mitral and aortic valves), or right heart catheterization (to assess blood flow, anatomy, and pressures in right heart chambers, anatomy and function of the tricuspid and pulmonic valves, pulmonary artery pressure, and pulmonary capillary wedge pressure). Determining emergency/urgency for revascularization dictates how extensive and how thorough the pre-cardiac catheterization management will be. In the case of emergencies (e.g. myocardial infarction), patient transfer to the catheterization laboratory and immediate revascularization (door-to-balloon) precede all other steps in management. In contrast, stable patients require a more extensive work-up pre-catheterization to minimize the risk of adverse events that may develop during or following the procedure.

Classification

Cardiac catheterization may be either:

• Diagnostic (no intervention), OR
• Therapeutic (percutaneous coronary intervention or PCI)

However, cardiac catheterization may also classified based on the cardiac structure in which the catheter is inserted:

Coronary Angiography

Insertion of the catheter into the coronary arteries. Coronary angiography assesses the patency of coronary arteries.

Left Heart Catheterization

Left heart catheterization (LHC) is the insertion of the catheter into the left ventricle. LHC is used to assess the following:

• Blood flow, anatomy, and pressures in left heart chambers
  
• The anatomy and function of the mitral and aortic valves

Right Heart Catheterization

Right heart catheterization (RHC) is the insertion of the catheter into the right ventricle and the pulmonary artery. RHC is used to assess the following:

• Blood flow, anatomy, and pressures in right heart chambers
  
• Anatomy and function of the tricuspid and pulmonic valves
• Pulmonary artery pressure
• Pulmonary capillary wedge pressure (PCWP)

Cardiac Catheterization Pre-procedure Evaluation

Boxes in red signify that an urgent management is needed.

Abbreviations: ASA: American society of anesthesiologists; BP: Blood Pressure; CCS: Canadian cardiovascular society; CrCl: Creatinine clearance; CXR: Chest X-ray; DNI: Do not intubate; DNR: Do not resuscitate; ECG: Electrocardiogram; eGFR: estimated glomerular filtration rate; HR:Heart rate; INR: International normalized ratio; LMWH: Low molecular weight heparin; LV: Left ventricle; LVED: Left ventricular ejection fraction; NOAC: Novel oral anticoagulant; NPO: Nothing per os; PMI: Point of maximal impulse; PT: Prothrombin time; RR: Respiratory rate; SpO2: Oxygen saturation; T: Temperature; VT: Ventricular tachycardia

Is cardiac catheterization an emergency?

Yes

No

Refer to management of acute coronary syndromes

Confirm that the patient has ANY of the following indications for cardiac catheterization Left heart catheterization ❑ CCS class III (i.e. symptoms with everyday living activities) or class IV angina (i.e. inability to perform any activity without angina or angina at rest) despite medical therapy, OR ❑ Angina plus systolic dysfunction, OR ❑ Uncertain diagnosis following non-invasive test and need to confirm diagnosis, OR ❑ Systolic dysfunction with unexplained cause, OR ❑ Survivor of sudden cardiac death, polymorphic VT, or sustained monomorphic VT, OR ❑ Suspected spasm or non-atherosclerotic cause of ischemia, OR ❑ High-risk stress test finding, defined as ANY of following : ❑ Resting LVEF < 35% ❑ High-risk treadmill score (≤ 11) ❑ Severe exercise LVEF < 35% ❑ Stress-induced large perfusion defect ❑ Stress-induced multiple perfusion defects ❑ Large, fixed perfusion defect with LV dilation OR increased lung uptake ❑ LV dilation or increased lung uptake ❑ Stress-induced moderate perfusion defect with LV dilation or increased lung uptake Right heart catheterization ❑ Patient in shock with unknown volume status ❑ Cardiogenic shock ❑ Diagnosis of follow-up of pulmonary artery hypertension ❑ Patients with advanced cardiopulmonary diseases who require surgery ❑ Left-to-right shunt ❑ Valvular disease ❑ Pulmonary artery hypertension ❑ Congenital heart disease

Obtain a detailed history History of Present Illness ❑ Age ❑ Chest pain or chest discomfort ❑ Onset of symptoms ❑ Sensation of heaviness, tightness, pressure, or squeezing ❑ Duration of each episode ❑ Radiation to the left arm, jaw, neck, right arm, back, or epigastrium ❑ Timing of symptoms (morning vs. evening vs. wake patient at night) ❑ Alleviating factors (e.g. medications or rest) ❑ Exacerbating factors ❑ Association of symptoms with food intake ❑ Palpitations ❑ Nausea or vomiting ❑ Sweating ❑ Dyspnea ❑ Orthopnea ❑ Dizziness ❑ Weakness of extremities ❑ Numbness or tingling of extremities ❑ Lightheadedness ❑ Syncope or presyncope ❑ Increased frequency of symptoms ❑ Worsening of severity ❑ Previous episodes ❑ Recent infections ❑ Fever ❑ Weight or appetite changes ❑ Stress ❑ Fatigue Possible Symptom Triggers ❑ Physical exertion ❑ Air pollution or fine particulate matter ❑ Recent infection ❑ Heavy meal intake ❑ Cocaine ❑ Marijuana Cardiovascular Risk Factors ❑ Known CAD (review available cardiac catheterizations or CABG reports) ❑ Smoking history ❑ Baseline blood pressure (Duration, antihypertensive therapy, compliance with medications) ❑ History of diabetes mellitus (Duration, DM control, compliance, antidiabetic medications, recent HbA1C, screening for microvascular and macrovascular DM complications) ❑ Dyslipidemia ❑ Obesity (BMI> 30 kg/m2) Past Medical History ❑ Congenital heart disease ❑ Left to right shunts ❑ Dextrocardia ❑ Situs inversus ❑ History of renal disease (CrCl < 60 mL/min)? Does the patient currently have a stable renal function? ❑ History of bleeding tendency ❑ Known significant anemia (Hct < 30%) ❑ History of heparin-induced thrombocytopenia (HIT) ❑ History of pulmonary disease ❑ History of major surgery in the past month ❑ Anticipated major surgery in the next year Medications ❑ Prescribed drug ❑ Home oxygen therapy ❑ Over-the-counter drugs ❑ Herbs and supplements ❑ Administration of ANY of the following medications within the last 48 hours prior to catheterization? ❑ Aspirin ❑ Clopidogrel ❑ Prasugrel ❑Ticagrelor ❑ Metformin ❑ Other oral antidiabetic agents ❑ Insulin injections ❑ Phosphodiesterase inhibitors (e.g. Tadalafil, sildenafil, or vardenafil) ❑ Warfarin. If yes, what is most recent INR? ❑ Unfractionated heparin or Low molecular weight heparin (LMWH). If yes, when was last dose? ❑ Other chronic anticoagualants (e.g. dabigatran, NOACs) Allergies ❑ List of allergies, including severity and manifestations (pruritus, rash, hives, stridor, or anaphylactic shock) ❑ Known drug allergies ❑ Allergy to aspirin or history of nasal polyps or aspirin desensitization ❑ Allergy to heparin ❑ Allergy to [sedative]]s ❑ Other drug allergies ❑ Contrast allergy ❑ Latex allergy ❑ Allergy to shellfish (controversial association between shellfish allergy and contrast allergy) ❑ Other known environmental and food allergies Family History ❑ Family history of premature cardiovascular diseases Social and Sexual History ❑ Healthcare proxy and available family members for patient care ❑ Barrier to tolerate or adhere to dual antiplatelet therapy (DAPT) or follow-up visits ❑ Pregnancy or possible pregnancy Advanced Directives ❑ DNR status ❑ DNI status

Examine the patient ❑ Vital signs, including BP, HR, RR, T, room air SpO2 ❑ Height (in meters), weight (in kilograms), and body mass index (BMI) ❑ Level of consciousness, orientation, and ability to cooperate and communicate Skin ❑ Xanthelesma or xanthoma (suggestive of dyslipidemia) ❑ Edema (suggestive of renal insufficiency or congestive heart failure) ❑ Acral and/or central cyanosis HEENT ❑ Head and neck range of motion ❑ Modified Mallampati score ❑ Class I: Soft palate, uvula, fauces, pillars visible ❑ Class II: Soft palate, uvula, fauces visible ❑ Class III: Soft palate, base of uvula present ❑ Class IV: Only hard palate visible Cardiothoracic ❑ Auscultation of heart sounds (including number of sounds, pitch, interval, murmurs, gallops, or rubs) over 4 precordial regions in sitting position (stethoscope diaphragm) and auscultation of mitral area while in left lateral decubitus position (stethoscope bell) ❑ Normal S1 and S2 ❑ S3 may be pathologic or may be a normal finding in young or pregnant ❑ S4 may be pathologic or may be a normal finding in elderly ❑ Murmur may be physiologic or may suggest valvulopathy or hemodynamic derangement (e.g. anemia) ❑ Pericardial friction rub may suggest pericarditis ❑ Point of maximal impulse (PMI) (normally one, non-sustained, tapping impulse per cardiac cycle located less than 2-3 cm from midclavicular line at 5th intercostal space) ❑ Auscultation of anterior and posterior pulmonic regions bilaterally ❑ Crackles suggest pulmonary edema, which might be attributed to congestive heart failure ❑ If pulmonary auscultation is abnormal, egophony, tactile fremitus, and thoracic percussion may be needed Vascular ❑ Pulses of both upper extremities (radial, ulnar, brachial) and lower extremities (dorsalis pedis, posterior tibial, popliteal) ❑ Femoral pulses bilaterally ❑ Femoral auscultation bilaterally for bruits ❑ Modified Allen test bilaterally to evaluate adequacy of radial access ❑ Carotid auscultation bilaterally ❑ Jugular venous pressure Neurological ❑ Upper/lower extremity motor strength ❑ Upper/lower extremity sensory exam ❑ Spasticity or rigidity ❑ Deep tendon reflexes ❑ Bilateral Babinski ❑ Cranial nerves assessment ❑ Coordination and cerebellar exams (Finger to nose, Romberg, heel to shin, alternating movement) ❑ Gait

Provide appropriate counseling before catheterization ❑ Address individual concerns and questions Hold Food Intake Before Procedure ❑ Keep patient NPO at least 6 hours before elective coronary angiography Hold Certain Medications Before Procedure Warfarin ❑ Hold warfarin for at least 2 to 6 days before elective coronary angiography (to prevent bleeding) ❑ Confirm INR < 1.8 (preferable INR < 1.4) within 24 hours before arterial puncture ❑ Restart warfarin 12 to 24 hours following catheterization (warfarin requires 2 to 3 days for INR to become therapeutic range) ❑ Consider heparin bridging 3 days before planned catheterization for high risk patients to prevent prolonged subtherapeutic INR ❑ Therapeutic dose LMWH 1 mg/kg subcutaneously twice daily for high-risk patients who are not at high risk of bleeding ❑ Intermediate dose LMWH 40 mg subcutaneously twice daily for high-risk patients at high risk of bleeding Novel Oral Anticoagulants ❑ Hold NOAC before catheterization as follow ❑ Rivaroxaban: Hold rivaroxaban for 2 days in patients with low bleeding risk OR for 3 days in patients with high bleeding risk ❑ Apixaban: Hold apixaban for 2 days in patients with low bleeding risk OR for 3 days in patients with high bleeding risk ❑ If patient does not develop any hematoma, restart NOAC 1 day after the catheterization for patients with low bleeding risk OR 2-3 days after the catheterization for patients with high bleeding risk Dabigatran ❑ Hold dabigatran based on renal function as shown below ❑ CrCl > 50 ml/min: Hold dabigatran for 1 day if low/intermediate bleeding risk or 3 days if high bleeding risk (e.g. major surgery) ❑ CrCl between 30 and 50 ml/min: Hold dabigatran for 3 days if low/intermediate bleeding risk or 5 days if high bleeding risk (e.g. major surgery) ❑ CrCl < 30 ml/min: Hold dabigatran for 2 to 5 days if low/intermediate bleeding risk or > 5 days if high bleeding risk (e.g. major surgery) ❑ If patient does not develop any hematoma, restart dabigatran 1 day after the catheterization for patients with low bleeding risk OR 2-3 days after the catheterization for patients with high bleeding risk LMWH ❑ Hold LMWH for 12 hours before cardiac catheterization ❑ Resume LMWH 12-24 hours following cardiac catheterization Metformin ❑ Hold metformin 2 days before elective coronary angiography ❑ Consider holding all other oral antidiabetic agents before elective coronary angiography and administering insulin instead ❑ Consider endocrinology consult for appropriate administration of antidiabetic agents before and after catheterization ❑ Restart metformin (or other oral antidiabetic agents) 2 days post-procedure OR until creatinine is stable (to prevent lactic acidosis and contrast-induced renal failure) Phosphodiesterase inhibitors ❑ Hold sildenafil/tadalafil/vardenafil for at least 2 days before elective cardiac catheterization ❑ Restart sildenafil/tadalafil/vardenafil one day after catheterization

Identify ASA physical status ❑ 1=Healthy individual with no systemic diseases ❑ 2=Mild systemic disease ❑ 3=Severe systemic disease ❑ 4=Severe systemic disease that poses a constant threat to the patient’s life ❑ 5=Moribund patient not expected to survive without the operation/procedure ❑ 6=Patient declared brain-dead or whose organs are being removed for donation

ASA physical status ≥ 4

ASA physical status < 4

Consult anesthesia

Perform pre-procedure routine work-up ❑ Complete blood count (CBC) ❑ Platelet count (Administration of unfractionated heparin, low molecular weight heparin, and parenteral glycoprotein 2b3a inhibitors are associated with thrombocytopenia. Thrombocytopenia is a contraindication to the administration of parenteral glycoprotein 2b3a inhibitors) ❑ Electrolytes panel ❑ Baseline serum creatinine and BUN. Calculate and record estimated creatinine clearance/eGFR (creatinine clearance/eGFR may significantly be different from true GFR in patients with unstable renal function) ❑ Glycemia ❑ ß-HCG within 2 weeks of procedure for women of child-bearing age ❑ Baseline ECG within 24 hours of procedure ❑ Assess baseline ischemic changes ❑ Presence of baseline bundle branch block (BBB) (Cardiac catheterization may damage HIS system and induce BBB) ❑ PT/INR within 24 hours, especially if patient is receiving warfarin (INR > 1.8 is a relative contraindication of cardiac catheterization) ❑ CXR if patient suspected to have pulmonary edema or other diseases

Address relevant and significant comorbidities ❑ Prolonged INR (>1.8) 24 hours prior to procedure ❑ Administer low-dose vitamin K 1-2 mg PO ❑ Repeat INR and confirm new INR < 1.8 (preferable INR ≤ 1.4). If INR still > 1.8 ❑ Administer additional vitamin K 2-4 mg PO if anticipated procedure is > 24 hours later. Administer more doses of low-dose vitamin K (1-2 mg PO) if INR still high ❑ Cancel transfemoral approach (except if emergency) if INR does not normalize in time of procedure ❑ Consider transradial approach if radial artery accessible to reduce risk of bleeding ❑ Consider transfusion of fresh frozen plasma (FFP) ❑ Renal insufficiency (CrCl < 60 ml/min) ❑ Saline administration ❑ In patients with no CHF, administer 0.9% or 0.45% normal saline: 1 mL/ kg/ hour (MAX 100 ml/hour) for 12 hours before contrast AND 12 hours after contrast) in patients with no CHF ❑ In patients with CHF, administer 0.45% normal saline: 0.5 ml/kg/hr (MAX 50 ml/hr) 12 hrs before contrast AND 12 hours after contrast ❑ Consider administration of sodium bicarbonate (NaHCO3) ❑ Mix 150 mEq of NaHCO3 in 1 liter of D5W in non-diabetic patients OR mix 150 mEq of NaHCO3 in 1 liter of sterile water in diabetic patients. ❑ Administer 3 ml/kg bolus (MAX 300 ml) for 1 hour prior to procedure AND 1 mL/kg/hour (MAX 100 ml/hr) during the procedure AND 1 mg/kg/hour for 6 hours post-procedure ❑ Follow-up serum creatinine 2 to 5 days following catheterization ❑ Contrast allergy ❑ Administer the following regimen before the procedure (controversial timing) ❑ Regimen 1 ❑ Methylprednisolone 60 mg IV once, AND ❑ Diphenhydramine 50 mg IV once, AND ❑ Cimetidine 300 mg (or alternative H2 blocker) IV once ❑ Regimen 2 ❑ Prednisolone 50 mg PO at 13 hours, 7 hours, and 1 hour (total of 3 doses) before procedure

Confirm pre-cath checklist on the day of the procedure ❑ Confirm patient full name ❑ Identify indication for procedure ❑ Planned procedure ❑ Diagnostic cardiac catheterization ❑ Diagnostic cardiac catheterization with possible PCI ❑ PCI ❑ Appropriate history and physical examination documented in patient record ❑ Informed consent is filled within 30 days, complete, signed, and available in patient record ❑ Candidacy for DES ❑ Does the patient have significant anemia (Hct < 30%) ❑ Has the patient had any major surgery in the past month or is anticipating any major surgery in the next year? ❑ Does the patient have clinically overt bleeding? ❑ Is the patient receiving chronic anticoagulation (e.g. warfarin or dabigatran) ❑ Does the patient have a history of medications non-adherence? ❑ Does the patient have someone available to transport to and from the hospital? ❑ Allergies and adverse drug reactions ❑ Contrast allergy. If yes, was the patient pre-treated? ❑ Aspirin allergy. If yes, does the patient need desensitization? ❑ Latex allergy: If yes, remove all latex products from procedural use ❑ Heparin induced thrombocytopenia (HIT): If yes, consider alterative antithrombotic agent ❑ Patient known to have multiple allergies? If yes, did you consider pretreatment? ❑ Medications ❑ Was the patient administered ANY of the following medications within the last 48 hours prior to catheterization? ❑ Aspirin ❑ Clopidogrel ❑ Metformin ❑ Phosphodiesterase inhibitors (e.g. Tadalafil, sildenafil, or similar drugs) ❑ Warfarin. If yes, what the patient’s pre-op (within 48 hours) INR? ❑ Low molecular weight heparin (LMWH). If yes, when was last dose? ❑ Other chronic anticoagualants (e.g. dabigatran, NOACs) ❑ ASA physical status available ❑ Modified mallampati score available ❑ Does patient have any contraindication to sedation? Sedatives are contraindicated in drug allergy, < 6 hours of NPO for solid food/non-clear liquids, < 2 hours of NPO for clear liquids, abnormal ECG findings, any condition that might compromise airway patency or that would interfere with intubation, hemodynamic instability, or clinically significant comorbidities ❑ Patient's height (in meter) and weight (in kilograms) recorded? ❑ Pre-procedural work-up available AND reviewed (CBC, electrolytes, glycemia, PT/INR, creatinine, BUN, PT/INR within 24 hours if receiving warfarin, ECG within 24 hours, CXR if applicable) ❑ Renal function (serum creatinine, BUN, creatinine clearance/eGFR) ❑ Bleeding risk (anemia, thrombocytopenia, prolonged INR/PT) ❑ Cardiac assessment (ECG)

Administer Preprocedural Drugs Antiplatelet therapy Aspirin ❑ Administer aspirin 325 mg PO once at least 2 hours before any cardiac catheterization procedure Thienopyridine A thienopyridine should be administered ONLY when there is intention for PCI or high likelihood to perform PCI during left heart catheterization. Generally, right heart catheterizations do not require administration of thienopyridine ❑ Administer ANY of the following thienopyridines at least 2 to 6 hours before the procedure ONLY when there is intention for PCI or high likelihood to perform PCI: ❑ Clopidogrel 600 mg (loading dose) PO once, OR ❑ Prasugrel 60 mg (loading dose) PO once, OR ❑ Ticagrelor 180 mg (loading dose) PO once Conscious Sedation Sedatives are contraindicated in drug allergy, < 6 hours of NPO for solid food/non-clear liquids, < 2 hours of NPO for clear liquids, abnormal ECG findings, any condition that might compromise airway patency or that would interfere with intubation, hemodynamic instability, or clinically significant comorbidities ❑ Administer diazepam 5-10 mg PO once ❑ Additional drugs may be administered pre-procedure, but are usually administered once patient is inside the cath lab. These drugs (combination) include: ❑ Fentanyl 25 to 50 microgram IV, AND ❑ Midazolam 1 to 2 mg IV Consider antihistamine ❑ Consider administration of diphenhydramine (Bendaryl) 25 mg PO once Consider anti-nausea agents ❑ Consider administration of ondansetron (Zofran) 4 mg IV once

Transfer patient to cath lab

Do's

• Perform a transradial approach instead of a transfemoral appraoach if radial artery is patent
• Hold anticoagulants, anti-diabetic agents, and phosphodiesterase inhibitors before the procedure
• Keep patient NPO at least 6 hours before the procedure
• Prepare the patient before the procedure if he is known to have contrast allergy, renal insufficiency, or diabetes mellitus
• Administer minimal among of contrast dye before a full injection to ensure the patient is not allergic or to confirm is adequately prepared
• Maintain the patient in a conscious state when administering sedatives

Don'ts

• Do not perform right heart catheterization (RHC) for routine management of pulmonary edema
• Do not perform RHC before a trial of intravascular volume expansion is attempted for low-risk patients
• Do not perform RHC for patients with certain cardiac tamponade, in whom RHC would delay treatment
• Do not perform RHC for patients with compensated heart failure undergoing low-risk non-cardiac surgery
• Do not administer thienopyridine if PCI will not be performed or unlikely to be performed during catheterization
• Do not remove compressive gauze at the site of injection before 24 hours of catheterization or before the patient is being discharged
• Do not insert the catheter at an infected site
• Do not perform catheterization if patient is pregnant (relative contraindication)
• Do not perform catheterization if the patient has uncontrolled hypertension or uncontrolled glycemia