From the Research
The minimum systolic ejection fraction (EF) recommended for an epidural steroid injection is typically 30%. Patients with an ejection fraction below 30% are generally considered high-risk for invasive procedures due to their compromised cardiac function. For patients with an EF between 30-40%, a cardiology consultation is often advised before proceeding with the epidural injection. The concern with low ejection fraction relates to hemodynamic instability that may occur during the procedure, particularly if vasovagal reactions or hypotension develop. The epidural space is highly vascular, and injections can potentially cause sympathetic blockade leading to vasodilation and decreased venous return, which could further compromise cardiac output in patients with heart failure. Additionally, the stress of the procedure itself may increase cardiac demand. For patients with borderline EF values, optimization of cardiac medications and careful monitoring during the procedure are essential to ensure safety. Some facilities may use slightly different thresholds based on their institutional protocols and the patient's overall clinical status.
Key Considerations
- The provided evidence does not directly address the minimum EF for epidural steroid injections, but guidelines for cardiac procedures suggest an EF of 30% as a threshold for increased risk 1.
- Epidural steroid injections can have systemic effects, including cortisol suppression, which may be relevant for patients with compromised cardiac function 2.
- The procedure's technical aspects and potential complications, such as hypothalamic-pituitary-adrenal axis suppression, adrenal insufficiency, and osteoporosis, should be considered when evaluating the risks and benefits of epidural steroid injections 3.
- Optimization of cardiac medications and careful monitoring during the procedure are crucial for patients with borderline EF values or other cardiac risk factors.
Clinical Implications
- Patients with an EF below 30% should be carefully evaluated and considered high-risk for epidural steroid injections.
- Cardiology consultation is recommended for patients with an EF between 30-40% before proceeding with the epidural injection.
- Facilities may use different thresholds based on their institutional protocols and the patient's overall clinical status.
- The use of nonparticulate steroids is recommended to minimize complications associated with epidural steroids 3.