Top Things to Know: Evidence-Based Practices in the Cardiac Catheterization Laboratory
Published: June 30, 2021
Prepared by Anne Leonard MPH, RN, FAHA – Sr. Science and Medicine Advisor - Lead
- More than 10 million cardiac catheterization procedures are performed every year in the United States. These procedures are done to confirm suspected coronary artery disease and/or other related disorders.
- Since the introduction of selective coronary angiography by Mason Sones in the 1950s, the catheterization procedure has evolved and expanded in scope and technique. Vascular areas now covered with coronary angiography include peripheral vascular and structural heart procedures in addition to coronary procedures.
- Periprocedural practices discussed in this statement include nothing by mouth (NPO). This statement discusses the rationale and considerations for a shorter NPO time prior to the procedure.
- Holding medications like the glucose-lowering agent metformin prior to procedures is common, but the evidence does not support deleterious effects from continuing metformin in patients with or without diabetes who have no or mild renal impairment.
- In patients at risk for contrast-associated acute kidney injury (CA-AKI), it is a common practice to advocate holding angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs). The rationale for this practice stems from the notion that ACEi/ARBs decrease the glomerular filtration rate (GFR) resulting in an increase in serum creatinine and predisposition toward CA-AKI. Patients without renal dysfunction can safely continue these medications during coronary angiography. This statement discusses when holding these medications is appropriate in persons with renal dysfunction.
- traditionally, anticoagulant therapy has been held prior to cardiac catherization. It is suggested that in patients who are at moderate or high risk of thrombotic complications (e.g., mechanical valves or patients with AF and prior stroke), continuation of oral anticoagulants (OACs) is reasonable, especially when diagnostic coronary angiography or percutaneous coronary intervention (PCI) can be performed via the transradial route. The decision to continue OACs should be made based on the thromboembolic risk association with PCI.
- “Allergies to shellfish”—patients with a history of shellfish allergy alone do not need premedication prior to cardiac catherization. In the patient with a previous moderate or severe acute reaction to contrast media, premedication prophylaxis for an allergic reaction would be appropriate.
- This statement also includes discussions around intra-procedure evidence-based practices for sedation, anesthesia, and analgesia in the cardiac catheterization laboratory.
- For magnetic resonance imaging (MRI) in patients with a newly implanted coronary stent, current practice is to avoid use of nonemergent MRI imaging examinations in the 4-6 weeks after stent implantation. Current consensus maintains that recent coronary artery implantation with a stent is not a contraindication to MRI.
- This scientific statement discusses several practices initiated prior to or in the catherization laboratory, not rooted in evidence but born by traditions based on beliefs and theoretical concerns. The evidence reviewed in this statement defines what is known about current thought and practice and offers suggestions on how to approach these common practices lacking evidence. A relook at these practices can potentially improve patient experience and safety avoid complications, and reduce cost.
Citation
Bangalore S, Barsness GW, Dangas GD, Kern MJ, Rao SV, Shore-Lesserson L, Tamis-Holland JE; on behalf of the American Heart Association Interventional Cardiovascular Care Committee of the Council on Clinical Cardiology; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Surgery and Anesthesia; and Council on Lifestyle and Cardiometabolic Health. Evidence-based practices in the cardiac catheterization laboratory: a scientific statement from the American Heart Association [published online ahead of print June 30, 2021]. Circulation. doi: 10.1161/CIR.0000000000000996