What are the pre-procedural preparations for heart catheterization?

Pre-Procedural Preparations for Heart Catheterization

Proper pre-procedural preparation for cardiac catheterization is essential to minimize complications and ensure optimal diagnostic results. The following guidelines outline the key preparations required before a heart catheterization procedure.

Patient Assessment and Preparation

• The physician performing the catheterization must thoroughly review the patient's history, physical examination, and pertinent laboratory data before the procedure, ideally the day before when possible 1
• The procedure should be timed when conditions such as arrhythmias, congestive heart failure, or azotemia are stable or improving to avoid misleading physiological data and increased procedural risks 1
• Informed consent must be obtained by the physician performing the procedure, with a detailed discussion of the reasons for the study, potential benefits, complications, and a description of the examination 1

Laboratory Testing and Risk Assessment

• All patients should be evaluated for bleeding risk before the procedure 1
• Glomerular filtration rate should be estimated, and dosages of renally cleared medications should be adjusted accordingly 1
• Patients should be assessed for risk of contrast-induced acute kidney injury (AKI) before the procedure 1
• In patients with chronic kidney disease (creatinine clearance <60 mL/min), the volume of contrast media should be minimized 1

Anticoagulation Management

• For patients on oral anticoagulants, management depends on the type of anticoagulant:
  • Warfarin: Can be continued at modified doses for most cardiac catheterizations, particularly when using radial approach 1
  • For trans-septal catheterization, direct LV puncture, or pericardial drainage, oral anticoagulants should be stopped and bridging anticoagulation performed 1
  • When bridging is required, the last dose of low molecular weight heparin (LMWH) should be administered >12 hours before the procedure, while unfractionated heparin (UFH) should be discontinued 4 hours before surgery 1
• Effective anticoagulation should be resumed as soon as possible after the procedure according to bleeding risk 1
• Combined aspirin therapy, if required, should be discontinued 1 week before a non-cardiac procedure after careful risk-benefit assessment 1

Antiplatelet Therapy

• Patients already on daily aspirin therapy should take 81 mg to 325 mg before the procedure 1
• Patients not on aspirin therapy should be given non-enteric aspirin 325 mg before the procedure 1
• For patients requiring high-dose statins, administration before the procedure is reasonable to reduce the risk of periprocedural myocardial infarction 1

Hydration and Contrast Nephropathy Prevention

• All patients undergoing cardiac catheterization with contrast media should receive adequate preparatory hydration to prevent contrast-induced nephropathy 1
• Administration of N-acetyl-L-cysteine is not useful for the prevention of contrast-induced AKI 1

Allergy Prophylaxis

• Patients with prior evidence of anaphylactoid reaction to contrast media should receive appropriate prophylaxis before repeat contrast administration 1
• In patients with a history of allergic reactions to shellfish or seafood, anaphylactoid prophylaxis for contrast reaction is not beneficial 1

Procedural Considerations

• Protection measures for both patients and staff should be implemented, including appropriate personal protective equipment such as gloves, gowns, and laboratory coats 1
• For more complex and lengthy procedures, more rigorous sterile technique should be followed 1
• Heparin should be routinely administered when nonionic contrast agents are used for angiography, as these agents inhibit blood clotting and platelet aggregation less than ionic agents 1

Post-Procedural Planning

• Standard post-procedural orders should include checking and recording blood pressure, pulse, distal pulses, and status of bandage sites every 15-30 minutes for 2 hours, then every hour for several hours 1
• A member of the catheterization team should examine the patient later in the day and subsequently as indicated 1
• An adequate post-procedural holding area should be available, especially for patients undergoing ambulatory catheterization 1

Common Pitfalls to Avoid

• Failing to identify patients at high risk for complications (advanced age, low body mass index, chronic kidney disease, baseline anemia) 2
• Inadequate hydration before contrast administration, which increases the risk of contrast-induced nephropathy 1
• Improper management of anticoagulation, particularly when bridging is required 1
• Overlooking the need for bleeding avoidance strategies such as radial artery access, which can reduce access-related bleeding and complications compared to femoral access 1
• Failure to restart anticoagulation post-procedure, which can expose patients to risk of stroke 2

By following these comprehensive pre-procedural preparations, the risks associated with cardiac catheterization can be minimized while ensuring optimal diagnostic results.