What preoperative questions should be asked before a cardiac catheterization?

Preoperative Questions for Cardiac Catheterization

Before cardiac catheterization, you must systematically assess for active cardiac conditions requiring stabilization, procedural contraindications, and factors that increase complication risk—specifically targeting unstable coronary syndromes, decompensated heart failure, significant arrhythmias, severe valvular disease, renal function, contrast allergy history, anticoagulation status, and vascular access concerns.

Critical Active Cardiac Conditions to Identify

Ask directly about symptoms suggesting conditions that mandate postponement or urgent treatment 1, 2:

• Unstable or severe angina: "Do you have chest pain at rest or with minimal activity? How many blocks can you walk before stopping?"
• Recent myocardial infarction: "Have you had a heart attack in the past month?"
• Decompensated heart failure: "Are you short of breath at rest or lying flat? Do you sleep on multiple pillows? Have you gained weight or noticed swelling?"
• Significant arrhythmias: "Do you have a pacemaker or defibrillator? Have you had episodes of rapid heartbeat, dizziness, or syncope?"
• Severe valvular disease: "Have you been told you have a heart valve problem? Do you get short of breath or dizzy with exertion?"

Functional Capacity Assessment

Determine exercise tolerance using specific metabolic equivalent (MET) thresholds 3, 4, 5:

• Less than 4 METs (high risk): Cannot climb one flight of stairs, walk up a hill, or do heavy housework
• 4-10 METs (moderate): Can climb stairs but cannot run or do strenuous sports
• Greater than 10 METs (low risk): Can participate in swimming, singles tennis, or running

Ask: "Can you climb a flight of stairs without stopping? Can you walk four blocks at a normal pace? Can you do heavy housework or yard work?"

Renal Function and Contrast Risk

Identify contrast nephropathy risk factors 1, 2:

• "Do you have kidney disease? What is your creatinine level?" (Creatinine >2.0 mg/dL is high risk)
• "Do you have diabetes requiring insulin?"
• "Have you ever had a reaction to X-ray dye or contrast?"

Bleeding and Vascular Complications Risk

Assess hemorrhagic and access site complications 1, 2:

• "Are you taking blood thinners—warfarin, heparin, or newer anticoagulants like apixaban or rivaroxaban?"
• "Are you on aspirin, clopidogrel, or other antiplatelet drugs?"
• "Do you have a bleeding disorder or easy bruising?"
• "Have you had problems with leg arteries or prior catheterizations?"
• "Do you have severe high blood pressure?" (Uncontrolled hypertension increases bleeding risk)

Medication Reconciliation

Document all current medications with exact doses 2:

• Antiplatelet agents (aspirin, P2Y12 inhibitors)
• Anticoagulants (warfarin, DOACs, heparin)
• Antiarrhythmics
• Vasopressors or vasodilators
• Herbal supplements and over-the-counter drugs

Comorbidities Increasing Procedural Risk

Screen for conditions that elevate morbidity and mortality 1, 2, 6:

• Pulmonary disease: "Do you have COPD, asthma, or get short of breath easily?" (Hypoxemia risk)
• Peripheral vascular disease: "Do you have leg pain with walking or poor circulation?"
• Cerebrovascular disease: "Have you had a stroke or TIA in the past 3 months?" (Recent stroke is high risk)
• Diabetes control: "Is your diabetes well-controlled? Do you take insulin?"
• Infection: "Do you have fever or active infection?" (Active endocarditis is particularly high risk)

Specific High-Risk Scenarios

Identify patients requiring inpatient monitoring rather than ambulatory procedures 2, 7:

• Congestive heart failure (NYHA Class III-IV)
• Left ventricular ejection fraction ≤35%
• Severe aortic stenosis (mean gradient >40 mmHg, valve area <1.0 cm²)
• Pulmonary hypertension or arterial desaturation
• Mechanical prosthetic valves on anticoagulation
• Morbid obesity
• Age <21 years or complex congenital heart disease
• Geographic remoteness (>1 hour from facility)

Radiation and Anesthesia Considerations

For pediatric or complex cases 6:

• "Will general anesthesia be required?" (Assess anesthesia risk)
• Discuss radiation exposure concerns, especially in young patients
• For children: assess for congenital heart disease complexity

Informed Consent Elements

The physician performing the procedure must personally discuss 2:

• Reasons for the study and expected benefits
• Specific complications: hypotension, myocardial ischemia, heart failure, renal failure, contrast reactions, retroperitoneal bleeding, cardiac tamponade, vascular problems, arrhythmias, stroke, and death 1, 6
• Alternative diagnostic approaches
• Post-procedural monitoring requirements

Common Pitfalls to Avoid

• Do not proceed if arrhythmias, heart failure, or azotemia are unstable—wait until conditions improve 2
• Do not assume blood pressure alone reflects cardiac output; hypotension requires hemodynamic assessment 8
• Do not overlook the timing of anticoagulation management, particularly with mechanical valves
• Do not perform left ventricular puncture or transseptal procedures in ambulatory settings 2, 7

This systematic approach prioritizes identification of conditions that increase mortality and morbidity, allowing for appropriate risk stratification, procedural timing, and monitoring intensity decisions.