The American Heart Association (AHA) has published a scientific statement challenging “traditionally held” cath lab practices, and instead offering evidence-based recommendations where these could be reconsidered.
Published in Circulation, the review authored by Sripal Bangalore (New York University Grossman School of Medicine, New York, USA) and colleagues, highlights common pre-, intra-, and post-procedure cath lab practices where evidence has accumulated over time, and may point to a change in approach.
Speaking to Cardiovascular News, Bangalore said: “The document outlines the evidence—or lack thereof—for certain practices in the cath lab. I think it is high time that we abandon age old practice and move more towards evidence-based practice. We hope this scientific statement from the AHA will empower cath labs to change their practice.”
In their review, Bangalore and colleagues consider the common practice of requiring patients to have nothing by mouth past midnight or for several hours before a cardiac catheterisation procedure, acknowledging that this is an “age-old” practice. However, the review suggests that evidence for this is “weak” and may not be necessary for patients who undergo procedures with only local anaesthesia and no sedation.
Bangalore et al also address the practice of withholding medications prior to any catheterisation procedure, including the use of metformin, glucose-lowering medications, renin-angiotensin blockers and oral anticoagulants.
Turning to intraprocedure evidence-based practices, Bangalore and colleagues review sedation, anaesthesia and analgesia considerations, noting that most procedures performed in the cardiac cath lab are done using conscious sedation, with general anaesthesia reserved only for the most complex and critically ill patients.
Considering the need for opiates, the authors write that, in most patients, opiates may not be needed to achieve optimal sedation, and the risk of opioid dependency is a concern. For this reason, they note that the use of opiates in non-elderly patients can be individualised based on the complexity of the procedure and the response to initial sedation with an anxiolytic agent alone.
Looking at vascular access, the reviewers acknowledge that, since 2006, the adoption of radial access for coronary angiography and percutaneous coronary intervention (PCI) has steadily grown. They write that randomised trials and observational studies have shown that radial access reduces major bleeding and vascular complications, and in high-risk patients, including those with ST-segment elevation myocardial infarction (STEMI), may reduce mortality. “Despite this body of data, the use of the radial approach lags behind in some subgroups,” they add, before offering some considerations for specific groups including patients with prior mastectomy, with abnormal collateral hand circulation, or those needing coronary artery bypass graft (CABG) surgery.
In terms of the postprocedure evidence considered, Bangalore and colleagues discuss the use of magnetic resonance imaging (MRI) in patients with a newly implanted coronary stent, noting that this is commonly avoided for around four-to-six weeks after stent implantation. However, the authors also state that current consensus maintains that recent coronary stent implantation is not a contraindication to MRI, writing that there are no published reports of adverse events associated with performing MRI in a patient following commercially available coronary stent implantation.