Non-emergent Cardiac Catheterization Research Articles

Feasibility of clinical pharmacist-led CYP2C19 genotyping for patients receiving non-emergent cardiac catheterization in an integrated health system.

Objective:To assess the feasibility of clinical pharmacist-led CYP2C19 genotype-guided P2Y12 inhibitor antiplatelet drug therapy recommendations to cardiologists in an outpatient cardiology practice.Methods:This was a prospective, open-labeled, single-arm study conducted in an integrated healthcare delivery system between March 1, 2013 and January 23, 2014. Patients requiring non-emergent cardiac catheterization were included. A clinical pharmacist provided interpretation and recommendations from genotyping results. The feasibility of implementing CYP2C19 genotype-guided antiplatelet therapy was assessed by the: 1) percentage of patients approached who consented to CYP2C19 genotyping, 2) percentage of patients with CYP2C19 genotyping results available prior to cardiac catheterization, and 3) percentage of clinical pharmacist CYP2C19 genotype-based antiplatelet recommendations accepted by cardiologists.Results:Of the 43 patients identified for potential recruitment, 22 of these were eligible for study enrollment and 6 (27%) patients consented and received CYP2C19 genotyping. All patients had genotyping results available prior to catheterization and all clinical pharmacists’ antiplatelet therapy recommendations were accepted by the patients’ cardiologists. Three patients had the CYP2C19 wild-type (*1/*1) genotype and the clinical pharmacist recommended clopidogrel therapy. CYP2C19 variant genotypes (i.e., *1/*2, *1/*17, and *2/*17) were found in the other three patients; alternative antiplatelet therapy was recommended for the patient with the *1/*2 genotype, while clopidogrel was recommended for those with *1/*17 and *2/*17 genotypes.Conclusion:A relatively small proportion of patients undergoing non-emergent cardiac catheterization consented to pharmacogenetic testing; however, their cardiologists were receptive to clinical pharmacists conducting such testing and providing corresponding pharmacotherapy recommendations. Future studies should identify patient barriers to pharmacogenetic testing.

Depressive symptoms and functional decline following coronary interventions in older patients with coronary artery disease: a prospective cohort study.

BackgroundDepressive symptoms are prevalent in patients with coronary artery disease (CAD). It is unclear, however, how depressive symptoms change over time and the impact of these changes on long-term functional outcomes. We examined the association between different trajectories of depressive symptoms over 1 year and change in functional status over 30 months among patients undergoing coronary angiography.MethodsThis was a prospective cohort study of 350 patients aged 60 and older undergoing non-emergent cardiac catheterization (October 2003–February 2007). A dynamic measure of significant depressive symptoms (i.e., Geriatric Depression Scale score 5+) capturing change over 12 months was derived that categorized patients into the following groups: (i) no clinically important depressive symptoms (at baseline, 6 and 12 months); (ii) baseline-only symptoms (at baseline but not at 6 and 12 months); (iii) new onset symptoms (not at baseline but present at either 6 or 12 months); and, (iv) persistent symptoms (at baseline and at either 6 or 12 month assessment). Primary outcomes were mean change in Older Americans Resources and Services (OARS) instrumental (IADL) and basic activities of daily living (BADL) scores (range 0–14 for each) across baseline (pre-procedure) and 6, 12, and 30 months post-procedure visits.ResultsEstimates for the symptom categories were 71 % (none), 9 % (baseline only), 8 % (new onset) and 12 % (persistent). In adjusted models, patients with persistent symptoms showed a significant decrease in mean IADL and BADL scores from baseline to 6 months (−1.32 [95 % CI −1.78 to −0.86] and −0.63 [−0.97 to −0.30], respectively) and from 12 to 30 months (−0.79 [−1.27 to −0.31] and −1.00 [−1.35 to −0.65], respectively). New onset symptoms were associated with a significant decrease in mean IADL scores at 6 months and from 6 to 12 months. Patients with no depressive symptoms showed little change in scores whereas those with baseline only symptoms showed significant improvement in mean IADL at 6 months.ConclusionsPatients with persistent depressive symptoms were at greatest risk for worse functional status 30 months following coronary interventions. Proactive screening and follow-up for depression in this population offers prognostic value and may facilitate the implementation of targeted interventions.Electronic supplementary materialThe online version of this article (doi:10.1186/s12888-016-0986-3) contains supplementary material, which is available to authorized users.

Abstract 119: Daily Cardiac Catheterization Procedural Volume and Complications

Background: Cardiac catheterization (CC) is a frequently performed procedure in US with over 1,000,000 procedures performed annually. Prior studies have demonstrated an inverse relationship between annual volume and complications with centers performing greater than 400 procedures annually having fewer complications. However, there has not been any investigation into the optimal daily volume of procedures to ensure the lowest risk. The objective of this study is to determine the relationship between daily volume and complication rates and to identify an optimal volume of procedures per day. Methods: We used data captured retrospectively from the NCDR and Lumedx© database of adult patients undergoing non-emergent CC at a high-volume (>400 procedures/year) tertiary care hospital catheterization laboratory from January 2005 - June 2013. We excluded patients undergoing CC on weekends and after business hours. In the event of multiple CC, only the first event was utilized for this analysis. Complications examined included: death, post-procedure MI, cardiogenic shock, heart failure, stroke, tamponade, major bleeding, hematoma or acute kidney injury as defined by the NCDR database. We analyzed the relationship between the volume of CC conducted per day and rates of complications. Results: Overall, 13,819 patients were included who underwent 18,287 CCs on 2,150 days. The average age was 63 years (SD 12.5; range 18-95) and 61% (8,430/13,819) were men. A total of 396 complications occurred in 305 patients on 292 separate days with a 2.2% (396/18,287) CC complication rate. The average volume per day was 8.5 CCs. On the days with a complication, the median procedural volume was 10 CCs compared to 8 CCs on days without a complication (p<0.01). We found a low correlation between the rates of complication and CC volume (Spearman’s rho=0.12; p<0.01). There was a U-shaped relationship with a higher complication rates on days with 1-5 CC and days with > 12 CC. Overall, the lowest complication rates were observed on days with 10-12 events. Conclusions: There is a U-shaped association between CC volume and rates of CC related complications. Unlike prior studies which identified high annual volumes were associated with lower complication rate, our study results suggests that this relationship does not hold true for daily volume. There appears to be a daily limit at which complication rates begin to rise in proportion to volume. Higher complication rates were seen on days with very low CC volume (<5 procedures) and days with very high CC volume (>12 procedures). It is important that individual high volume CC labs consider a quality control analysis of their daily CC volume to determine the optimal volume associated with the fewest complications.

Prevalence of renal artery stenosis in patients undergoing cardiac catheterization

To investigate the prevalence of significant renal artery stenosis (RAS ≥50%), and to identify clinical predictors for significant RAS in patients with an elevated cardiovascular risk, such as those affected by ischemic heart disease. In patients with an elevated cardio-vascular risk, both atherosclerotic renovascular disease and coronary artery disease (CAD) are likely to occur. Prospectively from April 2007 to March 2008, all consecutive patients with ischemic heart disease undergoing non-emergent cardiac catheterization were also evaluated for atherosclerotic RAS by renal arteriography. A RAS ≥50% was considered as significant. A total of 1,298 patients underwent cardiac and renal angiography. Significant RAS was found in 70 out of 1,298 patients (5.4%). The presence of peripheral vascular disease, eGFR <67ml/min/1.73m(2), age >66years, dyslipidemia, CAD severity and pulse pressure >52mmHg were independent clinical predictors of significant RAS, and jointly produced a ROC AUC of 0.79 (95% CI 0.73-0.85, P<0.001). Based on these data, a prediction rule for significant RAS was developed, and it showed an adequate predictive performance with 64% sensitivity and 82% specificity. In a large cohort of patients undergoing coronary angiography, significant RAS is a relatively rare comorbidity (5.4%). A model based on simple clinical variables may be useful for the clinical identification of high CV risk patients who may be suitable for renal arteriography at the time of cardiac catheterization.

Converting the Informed Consent From a Perfunctory Process to an Evidence-Based Foundation for Patient Decision Making

Standard consent forms result in highly variable communication between patients and physicians. To enhance the consent process and facilitate shared decision making, we developed a World Wide Web-based program, PREDICT (Patient Refined Expectations for Deciding Invasive Cardiac Treatments), to systematically embed patient-specific estimates of death, bleeding, and restenosis into individualized percutaneous coronary intervention informed consent documents. We then compared patients' experiences with informed consent before and after implementation of PREDICT. Between August 2006 and May 2007, patients undergoing nonemergent cardiac catheterization who received the original consent form (n=142) were interviewed and compared with those who received the PREDICT consent form (n=193). Hierarchical modified Poisson regression models were used to adjust for clustering of patients within physicians. Compared with the original consent group, those in the PREDICT group reported higher rates of reading the consent form (72% versus 44%, relative risk [RR] 1.64, 95% confidence interval [CI] 1.24 to 2.16), increased perception of shared decision making (67% versus 45%, RR 1.48, 95% CI 0.99 to 2.22), and decreased anxiety (35% versus 55%, RR 0.70, 95% CI 0.53 to 0.91). Although there were no differences between groups in patients' ability to name complications of percutaneous coronary intervention, among patients who identified either death or bleeding as a potential complication, more patients in the PREDICT group recalled being informed of their estimated risk of that complication (death: 85% versus 62%, RR 1.37, 95% CI 1.03 to 1.82; bleeding: 92% versus 71%, RR 1.28, 95% CI 1.06 to 1.56). In this preliminary, single-center experience, individualized consent forms with patient-specific risks were associated with improved participation in the consent process, reduced anxiety, and better risk recall. PREDICT is one potential strategy for improving the current practice of obtaining informed consent for percutaneous coronary intervention.

Factors that Affect Back Pain among Hong Kong Chinese Patients after Cardiac Catheterization

Cardiac catheterization (CC) is a widely used cardiac investigation procedure in Hong Kong. However, back pain is frequently reported following CC due the prolonged bed rest after the procedure. The overall aim of this study was to examine factors associated with back pain among Hong Kong Chinese patients after femoral access for CC. A prospective study, nested within a randomized clinical trial (RCT), employing secondary analysis of an existing data set from 419 Chinese adults receiving nonemergency CC, were used. Following a review of literature, gender, age, history of back pain, type of dressing on the puncture site, length of bed rest duration, turning privilege during bed rest, catheter size used for CC, duration of the procedure, duration of hemostasis, and body weight were identified as potential factors affecting back pain level. Back pain was assessed at 6 h and the next morning after CC, using the Numeric Pain Intensity Scale (NPIS). Analysis was done using multivariate analysis of variance (MANOVA), after testing for normality of the distribution. Turning privilege (p = 0.001), age (p = 0.04), and body weight (p = 0.006) were significantly related to level of back pain at 6 h and the next morning after CC. Results of this study may help nurses have a better understanding about patients' physical needs and appropriate nursing interventions that can be planned to enhance patient comfort following CC.

The profile of cardiac patients with renal artery stenosis

ObjectivesWe examined the prevalence and severity of renal artery stenosis (RAS) in patients undergoing cardiac catheterization who were deemed at risk for RAS based on clinical or laboratory criteria for study entry, but who had not previously been suspected of having RAS. BackgroundThe diagnosis of atherosclerotic RAS remains problematic because its clinical manifestations are nonspecific. MethodsConsecutive patients undergoing non-emergent cardiac catheterization at a single institution during a 12-month period were evaluated using standardized clinical, laboratory, and angiographic criteria. Patients exhibiting at least one of four predefined selection criteria (severe hypertension, unexplained renal dysfunction, acute pulmonary edema with hypertension, or severe atherosclerosis) were prospectively registered and underwent coincident diagnostic renal angiography. ResultsRenal angiography was performed in 851 patients and was diagnostic in 837. Angiographically evident renal atherosclerosis was present in 39% of the population, with RAS ≥50% in 120 (14.3%) and severe stenosis (≥70%) in 61 (7.3%). Severe stenosis was present in 48 (7%) patients with severe atherosclerosis, 38 (16%) with renal dysfunction, 25 (9%) with hypertension, and 2 (22%) with acute pulmonary edema with hypertension. The prevalence was higher in those exhibiting multiple selection criteria. In a multivariate model, severe RAS was associated with age, female gender, reduced creatinine clearance, increased systolic blood pressure, and peripheral or carotid artery disease. ConclusionsIn a population at risk of, but not previously suspected of having RAS, severe RAS is associated with simple and readily determined clinical and laboratory patient characteristics. These data facilitate focused application of diagnostic renal angiography.

A Randomized Prospective Trial to Assess the Role of Saline Hydration on the Development of Contrast Nephrotoxicity

Though simple and attractive, the role of hydration for the prophylaxis of contrast nephrotoxicity has not been definitively established. We prospectively evaluated the role of deliberate saline hydration in patients undergoing nonemergency cardiac catheterization. Patients (n = 53) were randomized on the day prior to scheduled catheterization to one of two groups – group 1 (n = 27) received normal saline for 24 h (at a rate of 1 ml/kg/h) beginning 12 h prior to scheduled catheterization, and group 2 (n = 26) were allowed unrestricted oral fluids. Serum creatinine measured 24 and 48 h postcardiac catheterization was compared to the pre-randomization baseline value. The mean baseline calculated creatinine clearance was 79.6 ± 31.9 ml/min and the mean baseline creatinine was 106 ± 28 µmol/l. An increase in serum creatinine by at least 44.2 µmol/l (0.5 mg/dl), within 48 h of contrast exposure, was considered to represent clinically significant acute renal insufficiency. Ten subjects (18.9%) developed acute renal insufficiency. The incidence of acute renal insufficiency was significantly lower in group 1 (1 out of 27) as compared to group 2 (9 out of 26; p = 0.005 for comparison between groups; relative risk 0.11, 95% confidence interval 0.015 to 0.79). Twenty-four hours after contrast exposure, the mean increase in creatinine was less in group 1 vs. group 2 (8 ± 11 vs. 20 ± 21 µmol/l, p = 0.02). The increase in creatinine was not significantly different in group 1 vs. group 2 48 h after contrast exposure (12 ± 21 vs. 29 ± 40 µmol/l, p = 0.17). Deliberate saline hydration decreases the incidence of contrast-related acute renal failure and the severity of contrast-induced renal dysfunction in patients undergoing non-emergency cardiac catheterization.

Short-Term Effects of Coronary Angiographic Contrast Agents on Thyroid Function

Objective To determine the effect of two iodine-containing contrast agents used for coronary angiography on subsequent thyroid hormone concentrations. Methods We prospectively studied thyroid function in 56 patients, with no previous history of thyroid disease and normal findings on thyroid examinations, who underwent nonemergent cardiac catheterization. Thyroid hormone concentrations were assessed at baseline and at day 1 and day 7 after administration of a radiographic iodinated contrast agent (Renografin or Omnipaque). Results Use of Omnipaque and Renografin was not associated with significant changes in thyroid-stimulating hormone, total thyroxine, triiodothyronine resin uptake, free thyroxine index, or total triiodothyronine. Three patients had slightly increased thyroid-stimulating hormone concentrations at 7 days after angiography. Conclusion Administration of iodinated contrast agents for cardiac catheterization does not result in hyperthyroidism in patients with previously normal findings on thyroid examination. (Endocr Pract. 1997; 3:219-221)

Nonemergent cardiac catheterization and risk-stratified revascularization following thrombolytic therapy for acute myocardial infarction. A critical analysis of therapy in the community setting. University of North Carolina Cardiology Consortium

We evaluated a strategy for administering thrombolytic therapy without emergent cardiac catheterization to patients with acute myocardial infarction in community hospitals. Fifty-nine patients were treated with intravenous streptokinase and heparin, and referred for elective catheterization. Angioplasty or bypass surgery was performed only in patients judged to be at risk for reinfarction. One or more predetermined criteria for infarct segment viability were present in 47 (80%) of 59 patients. Angina recurred in 24 patients and enzyme-positive reinfarction in 9 patients, but only 2 patients developed new Q waves or a creatine kinase rise to over twice the normal value. Of 18 patients judged to be at low risk for reinfarction, only 1 required urgent angioplasty or bypass surgery. Fourteen-day mortality was 7% and infarct vessel patency was 94%. These data indicate that physicians in small community hospitals with a close relationship to a referral center and with a carefully designed protocol can administer thrombolytic therapy safely and effectively. By subsequent stratification of patients according to the risk of recurrent infarction, 22% of patients eligible for revascularization were spared urgent angioplasty or bypass surgery.

Nonemergent Cardiac Catheterization and Risk-Stratified Revascularization Following Thrombolytic Therapy for Acute Myocardial Infarction

We evaluated a strategy for administering thrombolytic therapy without emergent cardiac catheterization to patients with acute myocardial infarction in community hospitals. Fifty-nine patients were treated with intravenous streptokinase and heparin, and referred for elective catheterization. Angioplasty or bypass surgery was performed only in patients judged to be at risk for reinfarction. One or more predetermined criteria for infarct segment viability were present in 47 (80%) of 59 patients. Angina recurred in 24 patients and enzyme-positive reinfarction in 9 patients, but only 2 patients developed new Q waves or a creatine kinase rise to over twice the normal value. Of 18 patients judged to be at low risk for reinfarction, only 1 required urgent angioplasty or bypass surgery. Fourteen-day mortality was 7% and infarct vessel patency was 94%. These data indicate that physicians in small community hospitals with a close relationship to a referral center and with a carefully designed protocol can administer thrombolytic therapy safely and effectively. By subsequent stratification of patients according to the risk of recurrent infarction, 22% of patients eligible for revascularization were spared urgent angioplasty or bypass surgery.