Cardiac Cath

Why & How It Is Done

Product # 504C

by Julia Ann Purcell, RN, MN, FAAN

(Author Emerita)

Clinical Nurse Specialist, Cardiology 1968–1996 Emory University Hospital Atlanta, GA

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This book is written to help you understand cardiac catheterization. It should not be used to replace any of your doctor’s advice or treatment.

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Cardiac catheterization A cardiac cath is a test that shows if there are problems in the heart valves, chambers or main blood vessels. A cath also shows if there is any blockage in the heart arteries. It lasts about an hour, and you don’t have to be put to sleep. During a heart cath, a long thin tube (catheter) is moved through a blood vessel until it reaches the heart.

dye (contrast) enters heart’s left chamber (to assess the pumping ability of the heart) catheter

right coronary artery (RCA)

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left main artery

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Once the tube is in place, dye is injected through the catheter and pictures are made of the heart and arteries.

The dye is used to highlight the vessels and any issues within them.

catheter

left circumflex coronary artery (LCX) blockage left anterior descending coronary artery (LAD)

* Cardiac catheterization is also called cardiac or heart cath, coronary arteriogram, coronary angiogram or dye study of the heart.

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Before the cath You will be asked about your health, both past and present.

At this time, tell your doctor of any allergies you have to shellfish or other foods, medicines or X-ray dye (such as that used with kidney X-rays). If you are pregnant or think you might be, tell your doctor or nurse.

You will have blood tests and an ECG (electrocardiogram) sometimes called an EKG. Bring your bottles or a list of your medicines (and dosage) with you to the hospital. Follow your doctor’s advice about which medicines to stop and which to take on the day of your cath. "Blood thinners” (anticoagulants) like warfarin, Pradaxa® (dabigatran), Xarelto® (rivaroxaban), Eliquis® (apixaban), Savaysa® (edoxaban) and Lovenox® are often Let your doctor STOPPED 1 or more days before a heart cath. Many doctors know if you have had any caffeine ask their patients to TAKE their daily anti-platelet (ATP) drug(s) before a heart cath. Examples of ATP drugs include or nicotine.

Avoid alcohol aspirin, Plavix® (clopidogrel), Effient® (prasugrel) and for 2 days before Brilinta® (ticagrelor). your cath.

Bring your nitroglycerin (NTG) with you in case you have angina while in the hospital, but only use it under your doctor or nurse’s direction. Tell your doctor or nurse if you've used one of these in the past 24 hours: a sex-enhancing drug (Viagra®, Cialis®, or vardenafil) or a drug for lung high blood pressure (Revatio® or Adcirca®).

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If you have diabetes, you may be asked to hold diabetes medicines on the day of your cath.

Follow your doctor's advice about when to stop eating or drinking. This will lower the chance of nausea or vomiting during the procedure. Most people can eat or drink right after the cath.

Any hair near the place where the catheter will be put in is clipped away and the skin scrubbed with a special soap.

A small IV catheter is placed in an arm vein so that medicines can be given as needed.

You will wear a hospital gown for the cath. Before leaving your room, you will be asked to empty your bladder in the bathroom and put on a hospital gown. Leave your slippers, clothing and any necklaces with your family. Ask if you can wear your glasses, rings, watch, dentures or your own socks.

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The cath In the cath lab, you lie on a bed under an X-ray camera. Small pads (electrodes) are put on your chest to hook you up to an ECG machine.

This shows your heartbeat during the cath. There are screens overhead that your medical team will use to assist in your care. You may see these screens, but it might be easier if you close your eyes and focus on other things. The room is usually cool to keep the computers that control the X-ray equipment from overheating. The X-ray bed is firm.

The team will ask questions before the start of your procedure. During the cath, it is okay to let them know if you no longer feel at ease or are uncomfortable.

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A medicine is often given to relax you. If you tell your doctor you are allergic to X-ray dye, you may be given a special medicine to reduce or prevent a reaction.

neck (internal jugular) with veins

A cardiac cath is done by inserting a catheter through an artery or vein in the groin, arm or neck. You may feel burning or stinging as medicine is injected in the skin over the blood vessel. You may feel some pressure, but pain is not likely. Once the needle tip enters the blood vessel, a guide wire is moved into the artery or vein.

The catheter is a long, very thin tube. It is passed over the wire to the heart without pain. Blood vessels don’t have pain fibers.

Arm Arteries: brachial

radial

Leg Artery:

left and right femoral arteries

needle skin

guide wire

blood vessel

Ask your doctor which blood areas of your body will be used for your cath.

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You may be asked to cough during the cath to help move the catheter into place. When the catheter is in place, X-ray dye is injected. As the dye goes in, you may have a warm or hot feeling all through your body for 30 seconds or less. Some people notice slight nausea or extra heartbeats. You may also feel a false need to urinate (pee). These feelings should pass quickly and not come back. Pictures are then made of the heart’s pumping chambers and the arteries that supply the heart with blood. In some cases, extra blood flow measurements and closeup pictures of the fatty plaque may be needed.

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left main coronary artery

left circumflex coronary artery blockage

right coronary artery

left anterior descending coronary artery

When the X-ray pictures have been taken, the catheter is removed.

The total heart cath lasts between 1 and 2 hours, but may run

longer for some people.

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After the cath If you feel up to it, you may eat and drink right after the cath.

Extra fluids can soothe a dry mouth caused by medicine and help your kidneys get rid of the X-ray dye.

Leg artery If the groin (leg) artery was used, the hole in the artery can be sealed by one of these:

Firm pressure followed by a tight bandage and 2-4 hours of bed rest with the hip and knee of the cath leg straight.

A closure device (a collagen “plug”, purse-string metal clip or some other material) left in place within the artery to reduce the amount of time needed to stay still and lie flat.

Stitches placed inside the artery (Perclose®) with bed rest as needed to recover from sedatives used during the cath.

A small hemostasis pad with blood-clotting material may also be placed over the puncture site for several hours. This pad goes beneath any bandage and is removed within 24 hours - along with the bandage.

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Tips to prevent puncture site bleeding Keep your cath leg straight! Do not bend the knee of your

cath leg. You may be told not to lift your head off the pillow. Doing these may affect the artery seal.

Do not get out of bed during your bed rest! If you have trouble using a urinal or bedpan while lying on your back, tell the nurse.

Hold firm pressure over the bandage as an extra support

while you cough, laugh or sneeze.

If you feel like you may vomit, do not sit up! Turn to the side of the bed and keep your bandaged leg straight.

Call your nurse to check your blood pressure and to make sure you are not bleeding or dizzy before you get out of bed the first time (once bed rest is complete).

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No matter how the artery is sealed, you will be asked to slide from the cath table onto a stretcher or bed without bending your groin.

If pressure is used to help seal the artery, you may need more bed rest than if a closure device or stitches are used. Follow your nurse and doctor’s advice about bed rest to prevent bleeding and to recover from any sedatives given during the cath.

Tips for comfort Some back or leg ache is likely from having to lie still.

Ask your nurse for pain medicine before you get too sore.

Although you need to keep your cath leg straight, you don’t need to hold it stiff. Wiggling your ankle or toes or bending your other leg up from time to time will help.

A small towel or pillow under your back and/or a back massage (by a nurse) may help too.

If you have steps at home, place firm pressure over your site (through your clothes) and walk up or down the steps sideways and slowly for the first 48 hours.

Caution If you: feel sudden pain at the site notice warm, sticky or wet feelings on your leg or arm that was used, tell the nurse at once! This may mean you are bleeding!

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Neck vein Your cath team will hold pressure on your neck until they are sure your bleeding has stopped. A bandage or gauze may be added for more pressure. After a couple of hours, you will be allowed to go home.

Arm artery Some doctors prefer to use the radial artery near the thumb for cardiac catheterization. A small compression strap is often compression strap placed over the site for several (filled with air) hours. Rarely, an artery or vein near the elbow (brachial) is used instead. If so, a few stitches may be needed to close the blood vessel and skin afterwards. In either case, an armboard may be placed on the arm as a reminder not to bend the elbow or wrist for

several hours.

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When an arm artery is used for the cath, you can walk to the bathroom and around the room (with help) within 1 to 2 hours.

Your nurse must go with you the first time! Do not use your cath arm to lift, push, help you sit up or stand up for the rest of the day after the cath. Don't lift anything heavier than a gallon of milk. Also, frequent arm motions like typing, knitting or chopping vegetables may be off limits for another 24 to 72 hours. When an arm blood vessel is used for your cath, tell the doctor if your hand or arm turns blue or gets painful and cold to the touch.

You may see your care team use a syringe to add or take air out of your compression strap. If the syringe is left with you, do not try to do this on your own.

Other things to know about cardiac cath Tell the nurse of any discomfort in your chest, neck, jaw, arms

or upper back. Also let your nurse know if you feel short of breath, weak or dizzy. These feelings do not happen often. Medicines can relieve them.

A cardiac cath is considered a safe procedure, but any work done inside a blood vessel carries a small risk of problems.

These include reactions to the dye or bleeding. Life-threatening complications like heart attack, hemorrhage, kidney injury or stroke can occur, but are rare. Your doctor will discuss any risks that cardiac cath might hold for you and ask for a written consent.

Feel free to ask your doctor or nurse any questions about your cath.

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Results Many times a heart cath shows that the heart and blood vessels are normal.

But if the cath shows that there is a problem, your doctor can use these drawings to show you the problem and what can be done about it.

Left Coronary Artery: left main

Right Coronary Artery

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circumflex artery (Cx)

obtuse marginal left anterior descending (LAD)

posterior descending artery

mitral valve

pulmonic valve tricuspid valve

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aortic valve

Treatment Some of the treatments for heart problems include: medicines

changes in lifestyle

angioplasty and stents

surgery

Medicines Heart medicines may be prescribed to: keep blood fats (lipids) in normal range: – total blood cholesterol less than 200 mg/dL –HDL more than: –40 mg/dL (men) –50 mg/dL (women) – LDL less than 100 mg/dL (or less than 70 for people at very high risk) –triglycerides less than 150 mg/dL stabilize and reduce fatty plaque relax the blood vessels produce a regular, steady heartbeat

Note

If you used to take Viagra®, Cialis® or vardenafil (sexenhancing drugs) or Revatio® or Adcirca® (lung problems), ask your doctor about whether it is OK to keep using it and any special precautions needed.

make the pumping action of the heart stronger take excess fluid from the blood replace minerals (potassium) Once your doctor decides the type(s) and amount(s) of medicine needed, follow the schedule just as directed.

Name of drug

Dose

When to take

What for

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Changes in lifestyle Fatty buildup in the arteries (atherosclerosis) is related to the way we live. For this reason, most doctors will ask that you: quit smoking lower blood pressure (if high) eat less unhealthy fat, sodium and added sugar keep blood glucose under good control (diabetics) exercise (your doctor will tell you what kind and how much) lose weight (if you are overweight) reduce tension and stress Sometimes a cardiac cath shows there has been recent heart damage or an overall heart weakness. If so, you may need to limit activity for a time so healing can take place.

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Angioplasty and stents If the cardiac cath shows clogged arteries or vein bypass grafts, angioplasty may be needed. Angioplasty is when one or more catheters are guided under X-ray to the clogged artery or vein bypass to clear or compress the blockage so more blood can flow through. Often a piece of metal wire mesh (stent) is placed in a narrowed artery to prop it open and to help keep it open.

Some stents are bare metal. Newer stents are partially or fully absorbable. The most often used are drug-coated. These slowly release a drug which helps keep tissue from building up (restenosis) as the artery lining heals.

Anti-clotting medications are needed to prevent blood clots inside all stents. Studies show blood clots can occur even a year after a

drug-coated stent is put in. So people who have these stents are often told to take an aspirin a day for life and a second anti-clotting drug like Plavix®, Effient® or Brilinta® for an extended period of time. Follow your doctor’s advice about the medicines you should take.

before artery narrowed by fatty buildup

BALLOON CATHETER

BALLOON CATHETER

during

BALLOON CATHETER

after stent

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Heart surgery and catheter-based valve repair Bypass heart surgery is advised for some people with several blockages in multiple heart arteries. A bypass graft is placed around the narrowed part of the artery. This allows blood to flow freely into the tissues below the blockage. A leg vein or an artery from the upper body is used for the graft.

saphenous vein (leg) bypass graft

blockage

internal mammary artery (chest) bypass graft

blockage

Heart surgery is sometimes needed to replace a heart valve which has become scarred from an infection or pulled out of position when a heart chamber enlarges (stretches out). Sometimes less invasive catheter procedures are used to repair or replace heart valves. Examples include TAVI/TAVR® (transcutaneous aortic valve implant or replacement) and the insertion of a Mitra® clip for mitral valve repair. Other problems in the valves, heart chambers or major blood vessels can be present at birth and require surgery in childhood or later as an adult.

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Going home Unless you need other treatment right away, you can go home several hours after the cath. You will need a ride, since most hospitals will not let you drive for the rest of the day. Fatigue is common for a day or two. You can return to your normal routine in 1-2 days unless your doctor tells you not to. If you have a bruise and/or a small lump under the Band-aid at the puncture site, delay any hard physical activity like tennis or running for a longer period. Change the Band-aid® daily until the site is healed.

Tell your doctor right away if you notice new swelling, prolonged itching, rash or signs of infection (fever, drainage or hot, tender feelings) at the cath site.

You will be told when it’s OK to shower or take a tub bath.

Showers are often allowed after 24 to 36 hours. Tub baths are usually delayed a few days. If you develop a scab over the insertion site, do not pick at it. This is the body’s way of healing.

If an elbow artery was used, there may be stitches on the skin. If so, you should protect the site with a plastic covering when taking a shower or bath. Do this until after the stitches have been removed (6 to 10 days later in your doctor’s office).

We hope this book has helped you feel better about your heart cath. If you have questions or concerns about the procedure or results, ask your doctor or nurse.

PHYSICIAN REVIEWERS:

NURSE REVIEWER:

John S. Douglas, Jr., MD, FACC Professor of Medicine (Cardiology and Radiology) Emory University School of Medicine Director, Interventional and Cardiac Catheterization Laboratory Emory University Hospital Atlanta, GA

Jason Johnson, MHA, MSN, RN, CCT Northside Hospital Privileged Healthcare Strategies, LLC Atlanta, GA

Spencer B. King, III, MD, FACC Fuqua Chair of Interventional Cardiology The Atlanta Cardiovascular Research Institute Clinical Professor of Medicine Emory University Atlanta, GA Henry A. Lieberman, MD, FACC Associate Professor of Medicine (Cardiology) Former Director, Cardiac Catheterization Laboratory Emory Midtown Hospital Atlanta, GA

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The result for you: less tension, more healing and a good idea of what to ask your doctor, nurse or others.