Treatments

Since coronary arteries deliver blood to the heart muscle, any coronary artery disorder or disease can have serious implications by reducing the flow of oxygen and nutrients to the heart, which may lead to a heart attack and possibly death. Atherosclerosis (a build-up of plaque in the inner lining of an artery causing it to narrow or become blocked) is the most common cause of heart disease.

Coronary heart disease, or coronary artery disease (CAD), is characterized by the accumulation of fatty deposits along the innermost layer of the coronary arteries. The fatty deposits may develop in childhood and continue to thicken and enlarge throughout the life span. This thickening, called atherosclerosis, narrows the arteries and can decrease or block the flow of blood to the heart.

Risk factors for CAD often include:

• Smoking
• High LDL cholesterol, high triglycerides levels, and low HDL cholesterol
• High blood pressure (hypertension)
• Physical inactivity
• Obesity
• High saturated fat diet
• Diabetes

Controlling risk factors is the key to preventing illness and death from CAD.

The symptoms of coronary heart disease will depend on the severity of the disease. Some people with CAD have no symptoms, some have episodes of mild chest pain or angina, and some have more severe chest pain.

If too little oxygenated blood reaches the heart, a person will experience chest pain called angina. When the blood supply is completely cut off, the result is a heart attack, and the heart muscle begins to die. Some people may have a heart attack and never recognize the symptoms. This is called a “silent” heart attack.

When symptoms are present, each person may experience them differently. Symptoms of coronary artery disease may include:

• Heaviness, tightness, pressure, and/or pain in the chest behind the breastbone
• Pain radiating in the arms, shoulders, jaw, neck, and/or back
• Shortness of breath
• Weakness and fatigue

In addition to a complete medical history and physical examination, diagnostic procedures for coronary artery disease may include any, or a combination of, the following:

• Electrocardiogram (ECG). A test that records the electrical activity of the heart, shows abnormal rhythms (arrhythmias or dysrhythmias), and detects heart muscle damage.
• Stress test (also called treadmill or exercise ECG). A test that is given while a patient walks on a treadmill to monitor the heart during exercise. Breathing and blood pressure rates are also monitored. A stress test may be used to detect coronary artery disease, and/or to determine safe levels of exercise following a heart attack or heart surgery.
• Cardiac catheterization. With this procedure, X-rays are taken after a contrast agent is injected into an artery to locate the narrowing, occlusions, and other abnormalities of specific arteries.

Cardiac catheterization is performed to further evaluate coronary artery disease, valvular heart disease, congestive heart failure, and/or certain congenital (present at birth) heart conditions, such as atrial septal defect or ventricular septal defect, when other less invasive types of diagnostic tests indicate the presence of one of these conditions.

In cardiac catheterization (often called cardiac cath or coronary angiogram – CAG), a very small hollow tube, or catheter, is advanced from a blood vessel in the groin or arm through the aorta into the heart. Once the catheter is in place, several diagnostic techniques may be used. The tip of the catheter can be placed into various parts of the heart to measure the pressures within the chambers. The catheter can be advanced into the coronary arteries and a contrast dye injected into the arteries.

The use of fluoroscopy (a special type of X-ray, similar to an X-ray “movie”) assists the doctor in locating any blockages in the coronary arteries as the contrast dye moves through the arteries.

The patient will remain awake during the procedure, although a small amount of sedating medication will be given prior to the procedure to ensure the patient remains comfortable during the procedure.

Before the Procedure

• The patient should notify the doctor if he/she has ever had a reaction to any contrast dye, or if allergic to iodine.
• The patient should notify the doctor if he/she is sensitive to or allergic to any medications, latex, tape, and anaesthetic agents (local and general).
• The patient will need to fast for a certain period of time prior to the procedure, usually overnight.
• If the patient is pregnant or suspect that she may be pregnant, the doctor should be notified.
• The doctor should be notified if the patient has any body piercings on the chest and/or abdomen.
• The doctor should be notified about all medications (prescription and over-the-counter) and herbal supplements that the patient is taking.
• The patient may be asked to withhold certain medications prior to the procedure. The doctor will provide detailed instructions.
• The doctor should be notified if the patient has a history of bleeding disorders or if the patient is taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for the patient to stop some of these medications prior to the procedure.
• The doctor may request a blood test prior to the procedure to determine how long it takes for the patient’s blood to clot. Other blood tests may be done as well.
• The doctor should be notified if the patient has heart valve disease or if there is a pacemaker inserted.
• Based on the medical condition of the patient, the doctor may request other specific preparation.

During the Procedure

A cardiac catheterization or coronary angiogram (CAG) may be performed on an outpatient basis or as part of stay in a hospital. Procedures may vary depending on the condition of the patient and the doctor’s practices.

Generally, a cardiac catheterization follows this process:

• The patient will be asked to remove any jewellery or other objects that may interfere with the procedure. The patient may wear dentures or hearing aids.
• The patient will be asked to remove clothing and will be given a gown to wear.
• The patient will be asked to empty his/her bladder prior to the procedure.
• If there is excessive hair at the catheter insertion site (groin area), the hair may be clipped off.
• An intravenous (IV) line will be started in the patient’s hand or arm prior to the procedure for injection of medication and to administer IV fluids, if needed.
• The patient will be placed in a supine (on his/her back) position on the procedure table.
• The patient will be connected to an ECG monitor that records the electrical activity of the heart and monitors the heart during the procedure using small, adhesive electrodes. The patient’s vital signs (heart rate, blood pressure, breathing rate, and oxygenation level) will be monitored during the procedure.
• There will be several monitor screens in the room, showing the patient’s vital signs, the images of the catheter being moved through the body into the heart, and the structures of the heart as the dye is injected.
• The patient will receive a sedative medication in the IV before the procedure to help him/her relax. However, the patient will likely remain awake during the procedure.
• The patient’s pulses below the catheter insertion site will be checked and marked so that the circulation to the limb below the site can be checked after the procedure.
• A local anaesthetic will be injected into the skin at the insertion site. The patient may feel some stinging at the site for a few seconds after the local anaesthetic is injected.
• Once the local anaesthetic has taken effect, a sheath, or introducer, will be inserted into the blood vessel. This is a plastic tube through which the catheter will be inserted into the blood vessel and advanced into the heart. If the arm is used, a small incision (cut) may be made to expose the blood vessel for insertion of the sheath.
• The catheter will be advanced through the aorta to the left side of the heart. Fluoroscopy will be used to assist in advancing the catheter to the heart.
• Once the catheter is in place, contrast dye will be injected through the catheter to visualize the heart and the coronary arteries. The patient may feel some effects when the contrast dye is injected into the IV line. These effects may include a flushing sensation, a salty or metallic taste in the mouth, and/or a brief headache. These effects usually last for only a few moments.
• The patient should notify the doctor if he/she feels any breathing difficulties, sweating, numbness, nausea and/or vomiting, chills, itching, or heart palpitations.
• After the contrast dye is injected, a series of rapid, sequential X-ray images of the heart and coronary arteries will be made. The patient may be instructed to take in a deep breath and hold it for a few seconds during this time.
• Once sufficient information has been obtained, the catheter will be removed. The insertion site may be closed with a closure device that uses collagen to seal the opening in the artery, by the use of sutures, by using a clip to bind the artery together, or by applying manual pressure over the area to keep the blood vessel from bleeding. The doctor will determine which method is appropriate for the patient’s condition.
• If a closure device is used, a sterile dressing will be applied to the site. If manual pressure is used, the doctor (or an assistant) will hold pressure on the insertion site so that a clot will form. Once the bleeding has stopped, a very tight bandage will be placed on the site. A small sandbag or other type of weight may be placed on top of the bandage for additional pressure on the site, especially if the site is in the groin.
• The patient will be assisted to slide from the table onto a stretcher so that he/she can be taken to the recovery area.
• If the insertion was in the groin, the patient will not be allowed to bend the leg for several hours.
• If the insertion site was in the arm, the arm will be kept elevated on pillows and kept straight by placing the arm in an arm guard (a plastic arm board designed to immobilize the elbow joint). In addition, a plastic band (works like a belt around the waist) may be secured around the arm near the insertion site. The band will be loosened at given intervals and removed at the appropriate time as determined by the doctor.

After the Procedure

After the procedure, the patient may be taken to the recovery room for observation or returned to the hospital room. The patient will remain flat in bed for several hours after the procedure. A nurse will monitor the vital signs, the insertion site, and circulation/sensation in the affected leg or arm. The patient should immediately inform the nurse in case of any chest pain or tightness, or any other pain, as well as any feelings of warmth, bleeding, or pain at the insertion site. Bed rest may vary from two to six hours depending on the patient’s specific condition. If the physician has placed a closure device, bed rest may be of shorter duration.   In some cases, the sheath or introducer may be left in the insertion site. If so, the period of bed rest will be prolonged until the sheath is removed.

The patient may feel the urge to urinate frequently because of the effects of the contrast dye and increased fluids. After the specified period of bed rest has been completed, the patient may get out of bed.  The patient should move slowly when getting up from the bed to avoid any dizziness from the long period of bed rest. Pain medication may be given for pain or discomfort related to the insertion site or having to lie flat and still for a prolonged period.  The patient will be encouraged to drink water and other fluids to help flush the contrast dye from the body. Normal diet may be resumed after the procedure, unless the doctor decides otherwise. When the recovery period is completed, the patient may be discharged.

Rehabilitation

Once at home, the insertion site should be monitored for bleeding, unusual pain, swelling, and abnormal discoloration or temperature change at or near the insertion site. A small bruise is normal.  If a constant or large amount of blood is noticed at the site that cannot be contained with a small dressing, the doctor needs to be notified.

If a closure device has been used for the insertion site, specific information will be given regarding the type of closure device that was used and how to take care of the insertion site. There may be a small knot, or lump, under the skin at the site. This is normal. The knot should gradually disappear over a few weeks. It will be important to keep the insertion site clean and dry. Specific bathing instructions will be given.  The patient will be advised not to participate in any strenuous activities for a period of time after the procedure.

The doctor needs to be notified in case of the any of the following:

• Fever and/or chills
• Increased pain, redness, swelling, or bleeding or other drainage from the insertion site
• Coolness, numbness and/or tingling, or other changes in the affected extremity
• Chest pain/pressure, nausea and/or vomiting, profuse sweating, dizziness, and/or fainting

Risks / Complications

Complications occur in less than 2% of the cases

Radiation risk: There is always a slight risk of damage to cells or tissues from being exposed to any radiation, including the low levels of X-ray used for this test. But the risk of damage from the X-rays is usually very low compared with the potential benefits of the test.

Outlook

Cardiac catheterization is a test to check the heart and coronary arteries.  Test results will be reviewed by a cardiologist and will be available after the procedure. The doctors will be able to talk to the patient about some of the results immediately after the test.

Results will include whether:

• Coronary arteries are normal or have narrowing or blockage.
• The heart’s pumping action (ejection fraction) and pressures inside the heart chambers and blood vessels are normal.
• The heart valves are working normally.

Many conditions can affect the results of a cardiac catheterization. The doctors will discuss any significant abnormal results and further treatment plan.