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Michaelene Hargrove Deelstra
Cardiac catheterization is widely used for diagnostic evaluation and therapeutic intervention in the management of patients with cardiac disease. Nurses have an important role in precatheterization teaching, intracatheterization, and postcatheterization care. The many nursing responsibilities related to cardiac catheterization are outlined in the American College of Cardiology/Society for Cardiac Angiography and Interventions (ACC/SCA&I) Clinical Expert Consensus Document on Cardiac Catheterization Laboratory Standards.1
Cardiac catheterization developed as a result of 50 years of clinical effort. Werner Forssman performed the first documented cardiac catheterization in 1929. Guided by fluoroscopy, Forssman passed a catheter into his own right heart through an antecubital vein. He then walked upstairs to the radiology department and confirmed the catheter position by radiograph. The techniques of right and left heart catheterization were developed during the 1940s and 1950s.2
In 1953, the percutaneous techniques of arterial catheterization were introduced by Seldinger,5
and, in 1959, selective coronary arteriography was introduced by Sones et al.6
Important advances related to cardiac catheterization included the development of the Swan-Ganz catheter in 1970 for measuring right heart pressures and the thermodilution method for determination of cardiac output (CO); percutaneous coronary interventions (PCIs), including percutaneous transluminal coronary angioplasty, atherectomy, laser therapy, and stent placement; electrophysiologic mapping and catheter ablation for the management of arrhythmias; valvuloplasty; and noncoronary devices for patent foramen ovale atrial septal defect closure, and ventricular septal defect closure1
Although noninvasive diagnostic techniques have an important role, cardiac catheterization remains the most definitive procedure for the diagnosis and evaluation of coronary disease. Coronary angiography together with adjunctive technologies during angiography, including intravascular ultrasound (IVUS), fractional flow reserve (FFR), and coronary flow reserve (CFR), provide direct quantitative measurements to evaluate significance of coronary lesions. This chapter describes cardiac catheterization procedures and their possible complications. It also describes the nursing care given before and after catheterization and the interpretation of data as they relate to coronary artery disease (CAD).
INDICATIONS FOR CARDIAC CATHETERIZATION
Cardiac catheterization is indicated in a wide variety of circumstances. The most frequent use of cardiac catheterization is to confirm or define the extent of suspected CAD. Anatomical and physiologic severity of the disease is determined, the presence or absence of related conditions is explored, and the need for PCI can be determined. Cardiac catheterization also is used for the evaluation of patients with acquired (Chapter 29
) or congenital (Chapter 31
) heart disease. The ACC and the American Heart Association (AHA) have published guidelines for coronary angiography and indications for cardiac catheterization.7
Indications for coronary angiography are classified for specific clinical presentations, including risk stratification for patients with chronic stable angina and asymptomatic patients with ischemia on noninvasive stress testing, and patients with acute coronary syndrome: non-ST elevation myocardial infarction (NSTEMI) and ST elevation myocardial infarction (STEMI).8
Recommendations for Coronary Angiography for Risk Stratification in Patients With Chronic Stable Angina: ACC/AHA Practice Guidelines8
Class I indications:
Patients with disabling (Canadian Cardiovascular Society [CCS] class III and IV) chronic stable angina despite medical therapy. (Level of evidence: B)
High-risk criteria on noninvasive testing regardless of anginal severity. (Level of evidence: B) (Display 20-1
Patients with angina who have survived sudden cardiac death or serious ventricular arrhythmia. (Level of evidence: B)
Patients with angina and symptoms and signs of heart failure (HF). (Level of evidence: C)
Patients with clinical characteristics that indicate a high likelihood of severe CAD. (Level of evidence: C)
Recommendations for Coronary Angiography for Risk Stratification in Asymptomatic Patients: ACC/AHA Practice Guidelines8
Class IIa indications:
Class IIb indications:
Patients with inadequate prognostic information after noninvasive testing. (Level of evidence: C)
Patients with clinical characteristics that indicate a high likelihood of severe CAD. (Level of evidence: C)
Recommendations for Coronary Angiography in Patients With Unstable Angina (UA/NSTEMI: ACC/AHA Practice Guidelines)9
Class I indications:
Patients with UA/NSTEMI who have had prior PCI or coronary artery bypass graft surgery should be considered for early coronary angiography, unless data from previous coronary angiography indicate that further revascularization is unlikely to be possible.9
Recommendations for Coronary Angiography in Patients With Variant (Prinzmetal’s) Angina: ACC/AHA Practice Guidelines9
Class I indications:
Diagnostic investigation is indicated in patients with a clinical picture suggestive of coronary spasm, with investigation for the presence of transient myocardial ischemia and ST-segment elevation during chest pain. (Level of evidence: A)
Patients with episodic chest pain accompanied by transient ST-segment elevation. (Level of evidence: B)
Recommendations for Coronary Angiography in Patients With Postrevascularization Ischemia: ACC/AHA Practice Guidelines7
Class I indications:
Suspected abrupt closure or subacute stent thrombosis after percutaneous revascularization. (Level of evidence: B) (Chapter 23
Recurrent angina or high-risk criteria on noninvasive evaluation within 9 months of percutaneous revascularization. (Level of evidence: C) (Display 20-1
Recommendations for Coronary Angiography in Patients During the Initial Management of Acute Myocardial Infarction: ACC/AHA/Society for Cardiovascular Angiography and Interventions (SCAI) Practice Guidelines11
Class I indications:
Coronary angiography and primary PCI should be performed in patients with STEMI or myocardial infarction (MI) with new or presumably new left bundle-branch block who can undergo PCI of the infarct artery within 12 hours of symptom onset. (Level of evidence: A)
Patients younger than 75 years with ST elevation or presumably new left bundle-branch block who develop shock within 36 hours of MI and are suitable for revascularization that can be performed within 18 hours of shock. (Level of evidence: A)
Patients with severe congestive heart failure and/or pulmonary edema and onset of symptoms within 12 hours. (Level of evidence: B)
Recommendations for Patients After Fibrinolytic Therapy: ACC/AHA Practice Guidelines12
Class I indications:
Care of patients with STEMI is presented in Chapter 22
▪ SHORT-TERM RISK OF DEATH OR NONFATAL MI IN PATIENTS WITH UNSTABLE ANGINA/NSTEMI*
At least one of the following features must be present:
No high-risk feature, but must have one of the following:
No high- or intermediate-risk feature but may have any of the following features:
Accelerating tempo of ischemic symptoms in preceding 48 hours
Prior MI, peripheral or cerebrovascular disease, or CABG; prior aspirin use
Character of pain
Prolonged ongoing (more than 20 minutes) rest pain
Prolonged (more than 20 minutes) rest angina, now resolved, with moderate or high likelihood of CAD
Rest angina (more than 20 minutes) or relieved with rest or sublingual NTG
New-onset or progressive CCS class III or IV angina in the past 2 weeks without prolonged (more than 20 minutes) rest pain but with intermediate or high likelihood of CAD
Increased angina frequency, severity, or duration
Angina provoked at a lower threshold
New onset angina with onset 2 weeks to 2 months prior to presentation
Pulmonary edema, most likely due to ischemia
New or worsening MR murmur
S3 or new/worsening crackles
Hypotension, bradycardia, tachycardia
Age greater than 75 years
Age greater than 70 years
Angina at rest with transient ST-segment changes greater than 0.5 mm
Bundle-branch block, new or presumed new
Sustained ventricular tachycardia
Pathological Q waves or resting ST-depression less than 1 mm in multiple lead groups (anterior, inferior, lateral)
Normal or unchanged ECG
Elevated cardiac TnT, TnI, or CK-MB (e.g., TnT or TnI >0.1 ng/mL)
Slightly elevated cardiac TnT, TnI, or CK-MB (e.g., TnT >0.01 but <0.1 ng/mL)
*Estimation of the short-term risks of death and nonfatal cardiac ischemic events in UA (or NSTEMI) is a complex multivariable problem that cannot be fully specified in a table such as this; therefore, this table is meant to offer general guidance and illustration rather than rigid algorithms.
CABG, coronary artery bypass graft surgery; CCS, Canadian Cardiovascular Society; CK-MB, creatine kinase MB fraction; MR, mitral regurgitation; NTG, nitroglycerin; TnI, troponin I; TnT, troponin T.
Anderson, J. L., Adams, C. D., Antman, E. M., et al. (2007). ACC/AHA 2007 guidelines for the management of patients with unstable angina/NSTEMI. Journal of American College of Cardiology, 50, 1-157.
Adapted from AHCPR Clinical Practice Guidelines No. 10, Unstable Angina: Diagnosis and Management, May 1994 (124).
CONTRAINDICATIONS FOR CARDIAC CATHETERIZATION
Cardiac catheterization has relatively few contraindications. Any correctable illness or condition that, if corrected, would improve the safety of the procedure should be managed before catheterization. These conditions include uncontrolled ventricular irritability, uncorrected hypokalemia or digitalis toxicity, decompensated HF, and severe renal insufficiency or anuria unless dialysis is planned after the procedure. Preexisting renal insufficiency, particularly in patients with diabetes, and patients with prior anaphylactic reaction to contrast medium require special treatment before the procedure. Other relative contraindications are recent stroke (within 1 month); active gastrointestinal bleeding; active infection; severe, uncontrolled hypertension; and the patient’s refusal of the therapeutic procedures to be directed by the catheterization results.13
Anticoagulation is a relative contraindication. Routinely, oral anticoagulants should be withheld for 48 to 72 hours before catheterization to achieve an international normalized ratio below 2.0. In patients who must remain on anticoagulants, such as patients with prosthetic heart valves or hypercoagulable states, bridging therapy with heparin is used while prothrombin time is reversed or allowed to return to normal. Immediate reversal of prothrombin time can be facilitated by fresh frozen plasma and vitamin K administration.14
Patients suspected of having an acute coronary syndrome would have a cardiac catheterization performed during their hospitalization. Elective cases are usually admitted for cardiac catheterization the day of the procedure. The physician performing the catheterization explains the procedure and obtains informed consent before procedure admission.
Precatheterization orders usually include the following:
Standard 12-lead electrocardiogram (ECG).
Laboratory tests: complete blood count including platelets and differential, electrolytes, blood urea nitrogen (BUN), and creatinine.
Nothing by mouth after midnight (or after a light breakfast if catheterization is to be in the afternoon).
Premedication with a mild sedative may be given. During the procedure, a procedural sedation protocol should be followed.
Patients with renal insufficiency should be adequately hydrated before and after the procedure and a minimum amount of radiographic low-osmolar contrast medium should be used. The combination of N
-acetylcysteine and sodium bicarbonate infusion before and after contrast infusion has shown to reduce the risk of contrast induced nephropathy in patients with renal insufficiency.15
Patients with a history of allergy to previous contrast administration, asthma, or drug or food allergies with iodine-containing substances should receive low-osmolar contrast medium and pretreatment with steroids, antihistamine (diphenhydramine), and an H2
blocker (cimetidine or ranitidine) are also sometimes used.16
Patients who are fasting should take a reduced dose of insulin or hold dose as directed by physician. Oral diabetic agents are usually held the morning of the procedure. Metformin is held the day of the procedure and 48 hours after the catheterization.
Anticoagulation issues are directed by the physician. Acetylsalicylic acid (ASA) and antiplatelet medications are usually given before catheterization. Warfarin is generally discontinued 3 to 4 days before the procedure until the international normalized ratio is <2.0. Warfarin can be reversed with vitamin K or fresh frozen plasma. If the patient is receiving heparin therapy, heparin can be continued during the catheterization and discontinued for sheath removal.
Patient to void before going to catheterization laboratory.
There is no evidence-based data to support the prophylactic use of antibiotics.
Patients who wear dentures, glasses, or hearing aids should be sent to the laboratory wearing them. The patient is better able to communicate when dentures and hearing aids are in place. Glasses allow the patient to view the angiogram on the monitor and help keep the patient oriented to the surroundings.
Nursing Assessment and Patient Teaching
Nursing assessment and teaching are important parts of patient preparation. The nursing assessment includes the patient’s heart rate and rhythm, blood pressure, evaluation of the peripheral pulses of the arms and legs, and assessment of heart and lung sounds. The sites for best palpation of the patient’s dorsalis pedis and posterior tibial pulses are marked on the skin. This information will be used for comparison in evaluating peripheral pulses after the catheterization procedure. A procedural sedation assessment is performed, including assessment of the patient’s cardiovascular, respiratory, and renal systems. Care is taken to identify characteristics or conditions that may cause the patient to be at greater risk for complications associated with procedural sedation, such as a history of difficult intubation; history of difficulty with sedation; morbid obesity; sleep apnea; extremes of age; severe cardiac, respiratory, renal, hepatic, or central nervous system disease; and history of substance abuse.17
The nursing assessment also includes an evaluation of the patient’s emotional status and attitude toward catheterization.
Is this the patient’s first cardiac catheterization?
What are the patient’s apprehensions about the procedure?
What has the patient heard about cardiac catheterization? (Patients have sometimes heard “horror stories” from friends or acquaintances about catheterization experiences and may, therefore, need reassurance about the safety of the procedure.)
What decisions are being faced? (Patients may be facing good or bad news about the absence or presence and extent of disease. Thus, the period before catheterization most likely is a time of anxiety and fear for a variety of reasons. Discussion and reassurance may help to relieve some of these feelings.)
The catheterization laboratory confronts the patient with new sights, sounds, and experiences that may be intimidating and frightening. Teaching is aimed at preparing the patient for this experience and should begin in the physician’s office. In some institutions, patients are given a video to view before the procedure. A printed booklet to which the patient can refer is also helpful. The following points should be covered in patient teaching:
The patient is given nothing by mouth for 6 to 8 hours before the catheterization and is asked to void before arriving at the catheterization laboratory.
Medication is given before or during the procedure, if prescribed, but the patient is awake during the procedure.
The patient should be instructed in deep breathing, how to stop a breath without bearing down, and in coughing on request. With deep inspiration, the diaphragm descends, preventing it from obstructing the view of the coronary arteries in some radiographic projections. Bearing down (Valsalva maneuver) increases intra-abdominal pressure and may raise the diaphragm, obstructing the view. After the injection of contrast medium, coughing is requested to help clear the material from the coronary arteries. The rapid movement of the diaphragm also acts as a mechanical stimulant to the heart and helps prevent the bradycardia that may accompany the injection of contrast medium.18
The appearance of the laboratory should be explained to the patient, including the general function of the equipment.
The patient wears a gown to the laboratory.
The patient lies on a table that is hard and narrow.
The catheter insertion site is washed with an antibacterial scrub and hair is removed using a shaver. Usually, both groins are prepped to provide easy access to the other side for patients with peripheral vascular disease and obstructive disease preventing catheter advancement or sudden instability during the procedure requiring an intra-aortic balloon pump (IABP). The right groin is generally used because the operator standing on that side of the table has easier access.
The expected length of the procedure should be explained to the patient (approximately 1 hour for coronary angiogram and 2 hours with PCI). Complex procedures will be longer.
The patient is given a local anesthetic at the catheter entry site.
The patient may have warm sensation or experience nausea during injection of the coronary arteries with contrast medium, most commonly occurring with the injection of the ventricle during ventriculogram.
The patient should report angina, shortness of breath (SOB), and other symptoms to the staff.
The patient should be told the expected length of bed rest after the catheterization.
Outpatient Cardiac Catheterization
Improvements in cardiac procedures and decline in risk associated with diagnostic cardiac catheterizations have increased the number of outpatient procedures. Advantages include decreased costs and avoidance of an unnecessary overnight hospital stay. Patients considered for outpatient cardiac catheterization are those with stable coronary symptoms. Patients in whom the outpatient procedure is contraindicated include those with ACS (UA, NSTEMI, or STEMI); uncompensated HF; severe aortic stenosis; suspected left main coronary disease; known bleeding disorders; and metabolically unstable patients.
Patients needing preadmission to the hospital for cardiac catheterization include those who require continuous anticoagulation or who have significant renal insufficiency or brittle diabetes mellitus. Noninvasive testing may identify patients with high-risk coronary or valvular disease before catheterization. Additional considerations include the distance the patient lives from the hospital and the availability of someone to drive the patient home.1
Freestanding cardiac catheterization laboratories that are not physically attached to a hospital facility are available and are used for diagnostic studies. It is the responsibility of each freestanding laboratory to have a formal relationship with a referral hospital for emergency services. Patients studied at freestanding laboratories require thorough screening. High-risk patients must be excluded to avoid complications that require emergency services.1
Preprocedure teaching is best done before hospital admission. The content is similar to that for patients undergoing an inpatient procedure. Patients who have significant CAD or left main coronary disease or complications during the procedure are usually admitted to the hospital for overnight observation (Display 20-2
After a diagnostic procedure, the patient spends 2 to 6 hours in a short-stay unit, ambulatory recovery, or similar setting. Postprocedure orders are the same for inpatient and outpatient cardiac catheterization. After the required period of bed rest, postural blood pressure and heart rate are obtained and the patient is observed for 30 to 60 minutes while sitting, standing, and walking. During this time, discharge instructions are reviewed. The patient is then allowed to leave. Results of the catheterization are reviewed with the patient and/or family after the procedure by the cardiologist or before discharge. Patients who have had PCI routinely stay overnight for observation and monitoring and are discharged the following morning.
Cardiac Catheterization Laboratory
The cardiac catheterization laboratory is a specially equipped radiologic laboratory for the study of children and adults with known or suspected heart disease. The primary technical focus is the generation, recording, and display of high-quality x-ray images during diagnostic and interventional procedures. The ongoing trend toward more complex interventional procedures results in greater exposure to radiation for the patient and laboratory staff. This radiation exposure is monitored for safety.1
The technique of imaging has moved away from cineangiographic to digital images in most laboratories. The laboratory usually has the following equipment:
A patient support table, adjustable height, flat top whose locks can be released to allow the table top to move horizontally head-to-toe and side-to-side for “panning.”
Equipment for monitoring intracardiac pressures, CO determination, and physiologic recordings.
A suspended C-arm that rotates around the patient and allows variable angulations of the x-ray beam.
The image chain consists of a generator and cine pulse system, an x-ray tube, an image intensifier, an optical distributor, a 35-mm cine camera, and a television camera and monitor. The image chain produces fluoroscopy, which is the continuous presentation of an x-ray image on a fluorescent screen, allowing the viewing of structures in motion. The image intensifier receives the fluoroscopic image and increases its brightness, permitting filming (cinefluoroscopy) or digital acquisition of motion pictures and viewing of the image with a television camera, television screen, and videotape recorder. Although 35-mm film was originally used for recording, since 1998 all new images are permanently recorded digitally.
Single or biplane imaging system can be used. Biplane imaging provides simultaneous viewing of cardiac structures from two angles, which is helpful for congenital heart disease, transseptal punctures, and electrophysiology ablations.
Advanced cardiac life support drugs and equipment with a cardioverter-defibrillator available for emergency treatment.
Monitoring electrocardiographic activity with continuous ECG monitor display.
A standby pacemaker, either a temporary transvenous electrode and pulse generator system or an external transthoracic pacemaker.
▪ Figure 20-1 Modified Seldinger technique for percutaneous catheter sheath introduction. (A) Vessel is punctured by needle. (B) Flexible guidewire placed in vessel through needle. (C) Needle removed, guidewire left in place, and hole in skin around wire enlarged with scalpel. (D) Sheath and dilator placed over guidewire. (E) Sheath and dilator advanced over guidewire and into vessel. (F) Dilator and guidewire removed while sheath remains in vessel. (From Hill, J. A., Lambert, C. R., Vuestra, R. E., et al. . Review of techniques. In J. C. Pepine, J. A. Hill, & C. R. Lambert [Eds.], Diagnostic and therapeutic cardiac catheterization [3rd ed., p. 107]. Baltimore: Williams & Wilkins.)
Percutaneous catheterization is accomplished using the modified technique initially described by Seldinger (Fig. 20-1
The same technique is used for both arterial and venous entry. Using the modified Seldinger technique, the vessel is located and a local anesthetic is used to numb the puncture area. The percutaneous needle, with fluid-filled syringe attached, is inserted through the skin nearly parallel to the vessel and enters the front wall of the vessel. Entry of the needle into the vessel is verified by blood return into the syringe with aspiration. The syringe is removed, and a guidewire is passed through the needle into the vessel. The needle is then removed, and a nick is made in the skin with a no. 11 blade to create a hole large enough for a hemostatic introducer sheath to be advanced over the guidewire and placed within the vessel. Catheters are exchanged by inserting a guidewire into the catheter and inserting the catheter with the guidewire through the introducer sheath, into the vessel. A guidewire of length 4 to 6 cm is advanced past the distal end of the catheter so the wire leads as the catheter and wire are advanced to the aortic arch. The guidewire is removed from the catheter completely before catheter placement.
The femoral approach is the preferred site for catheterization. Location of the femoral stick is important to avoid vascular complications. The ideal puncture site should be in the common femoral artery (Fig. 20-2B
). Puncture of the artery at or above the inguinal ligament makes catheter advancement difficult and predisposes to inadequate compression, hematoma formation, and retroperitoneal bleeding. Puncture of the artery more than 3 cm below the inguinal ligament increases the chance that the femoral artery will divide into its profunda and superficial branches. Puncture into these branches can cause development of a pseudoaneurysm or thrombotic occlusion of a small vessel.20
Alternative arterial puncture sites include the brachial and radial arteries (Fig. 20-2A
). The brachial artery may be used in cases of known vascular disease of the abdominal aorta or iliac or femoral arteries. Before using the radial artery, an Allen test is performed to verify patency of the ulnar artery to ensure circulation to the hand. The small caliber of the radial artery mandates the use of small catheters. Injection of lidocaine, nitroglycerin, or calcium channel blocker through the sheath arm is usually necessary to control local spasm in the radial artery. Use of the radial or brachial approach allows for easier control of bleeding at the access site, eliminates the need for bed rest after the procedure, and facilitates earlier discharge of outpatients. Radial artery thrombosis is a potential complication of this approach.
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