What is Cardiac Catheterization: Indications and Contraindications
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What is Cardiac Catheterization: Indications and Contraindications

Cardiac catheterization and coronary angiography are the most common invasive diagnostic and therapeutic procedures performed by cardiologists. Catheterization is primarily used to diagnose obstructive coronary artery disease, assess its severity, and design the optimal medical and/or surgical treatment.
       cardiac catherization

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• Cardiac catheterization and coronary angiography are the most common invasive diagnostic and therapeutic procedures performed by cardiologists.

• These procedures involve insertion of a specialized catheter into the systemic circulation (usually via femoral artery puncture) and advancement into individual coronary arteries or retrograde advancement across the aortic valve and into the LV. In addition, a catheter can be placed through the venous system into the right sided chambers and pulmonary circulation.

• Following placement of the catheter in the desired location, hemodynamic data can be acquired, and angiography can be performed by injection of radiocontrast dye and fluoroscopic image acquisition.

• Catheterization is primarily used to diagnose obstructive coronary artery disease, assess its severity, and design the optimal medical and/or surgical treatment.

• Alternate uses of cardiac catheterization include the following:

  • To exclude CAD as a cause of left ventricular systolic dysfunction
  • To quantify the severity of left ventricular systolic dysfunction
  • To differentiate myocardial restriction from pericardial constriction
  • To assess the severity of valvular regurgitation
  • To detect active myocarditis or acute transplant rejection by means of endomyocardial biopsy

Indications

• Asymptomatic patients or stable angina:

  • Patients with high-risk findings on a noninvasive test regardless of symptoms
  • Patients with class III to IV angina that persists despite medical therapy or any patient with class I to II angina that is intolerant of medical therapy
  • Individuals in a high-risk occupation that affects the safety of others
  • Patients successfully resuscitated from sudden cardiac death

• Unstable angina:

  • Patients who are refractory to initial medical stabilization are subjected to emergent catheterization.
  • Patients who have high-risk characteristics (heart failure, rhythmic instability, etc) undergo urgent catheterization.
  • Patients with high-risk features on noninvasive testing

• Acute MI:

  • For primary revascularization in patients with an acute MI who present within 12 hours of symptom onset or at any time if symptoms persist (angina, heart failure, or electrical instability)
  • In patients younger than 75 years of age who suffer an acute MI complicated by cardiogenic shock within 36 hours
  • Patients in the post-MI setting with spontaneous ischemia or ischemia provoked by low level exertion or any patient with high-risk features on a postdischarge stress test

• Postrevascularization ischemia:

  • Suspected abrupt closure or subacute stent thrombosis after revascularization
  • Recurrent ischemia 9 months after percutaneous coronary intervention (PCI) or 12 months after bypass surgery

• Preoperative evaluation prior to noncardiac surgery:

  • Patients with high-risk findings on preoperative noninvasive evaluation
  • Any high-risk clinical patient with equivocal noninvasive test findings
  • Stable or unstable angina that is not responsive to adequate medical therapy

• Valvular heart disease:

  • Prior to valvular surgery to assess the coronary arteries

• Congenital heart disease:

  • Prior to surgical correction in patients with symptoms suggestive of ischemia or in patients with congenital abnormalities that are associated with coronary anomalies

• Congestive heart failure:

  • Patients with systolic dysfunction and chest pain or reversible ischemia on noninvasive testing
  • Patients with unexplained systolic dysfunction

• Other conditions:

  • Patients with any disease affecting the aorta when knowledge of coronary anatomy might affect management (ie, aortic dissection)
  • Prospective cardiac transplant donors who are at risk for CAD
  • Asymptomatic patients with Kawasaki disease to identify coronary artery aneurysms

Contraindications

• The only absolute contraindication to cardiac catheterization is refusal of the patient to undergo the procedure.

• Relative contraindications include the following:

  • Electrolyte abnormalities
  • Febrile illness
  • Acute renal failure
  • Decompensated heart failure
  • Severe allergy to radiographic contrast agents
  • Bleeding disorder or anticoagulated state
  • Severe, uncontrolled hypertension
  • Pregnancy

• In some emergent situations, a cardiac catheterization may be indicated despite the presence of one or more of these relative contraindications.

Complications and Safety

• Cardiac catheterization is a relatively safe procedure; however, like all invasive procedures it does carry risk.

• The risk of death, MI, or cerebrovascular accident is approximately 1 in 1000 procedures. The two major factors that have been associated with an adverse outcome include disease of the left main coronary artery and severe aortic stenosis.

• Vascular access site complications (ie, retroperitoneal hemorrhage, hematoma, pseudoaneurysm, distal embolization) occur in approximately 1 in 100 procedures.

• Contrast-induced nephropathy characterized by a transient elevation of the serum creatinine secondary to iodinated contrast. Diabetic renal disease (creatinine ??2.0 mg/dl) is most commonly associated with this complication. Several strategies have been employed to prevent contrast induced nephropathy including hydration, mannitol, diuresis, dopamine, fenoldopam, N-acetyl cysteine, bicarbonate, and hemofiltration. In addition, the physicochemical properties of the contrast agent are associated with contrastinduced nephropathy.

  • Currently accepted strategies for minimizing risk of contrast-induced nephropathy include limiting contrast volume, utilizing low-osmolar contrast, aggressive hydration (usually involving isotonic fluids or bicarbonate containing fluids), and avoidance of nephrotoxins such as NSAIDs in the periprocedural period. The use of N-acetyl cysteine can be considered although its efficacy is controversial.

• Importantly,the risk of renal atheroembolic disease is significant in patients with advanced large vessel atherosclerosis. Atheroemboli can induce digital ischemia and progressive renal dysfunction (often slowly over a period of months). Once established, renal atheroembolic disease is generally considered irreversible.

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