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Cardiac tests - catheterisation and angiography

Cardiologists Dr Clive Handler and Dr Gerry Coghlan continue their series on tests commonly used in primary care

Cardiologists Dr Clive Handler and Dr Gerry Coghlan continue their series on tests commonly used in primary care

The main purpose of this test is to obtain anatomical information on the location and severity of coronary artery disease and haemodynamic data. It provides superior information compared with non-invasive coronary artery imaging, and it also provides the opportunity to perform angioplasty at the same time.

The test

This test is performed by cardiologists as a day case. Using local anaesthesia (and in some patients, light sedation), small-lumen tubes are passed sequentially through a sheath inserted most commonly into the right femoral artery. The sheath is used to allow easy access to the artery and prevents forward flow of blood through the sheath, although blood can still flow to the foot outside the sheath. The left femoral, right radial and brachial arteries are also occasionally used in patients with difficult arterial access.

Different-shaped catheters are used to intubate and inject radio-opaque contrast into the left ventricle and the right and left coronary arteries. Another catheter may be used to measure pressures in the pulmonary artery and right heart chambers in patients with valvular disease or septal defects, and in the uncommon cases where cardiac transplantation is being considered.

The test is most commonly performed in patients with known or suspected coronary artery disease, when only the left ventricle and coronary arteries are catheterised.

Value, limitations, complications

41214314Coronary angiography is the ‘gold standard' test for investigating anatomical coronary artery disease, but it does not provide physiological information.

The percentage risks of coronary angiography in low-risk patients are small. Most complications occur in older patients with atheromatous vascular disease, which is the main indication for performing the investigation (see box, right).

The most common femoral artery vascular complications occur in patients with a wide pulse pressure, for example in hypertension and aortic regurgitation, and include haematoma or, less commonly, a false aneurysm of the femoral artery. These present as a painful, swollen and spreading bruise over the puncture site, and are diagnosed with duplex ultrasound.

All patients with a painful, swollen, pulsatile mass over the puncture site should be referred back to the cardiologist for assessment. False aneurysms may close up and heal spontaneously if there is low flow between the main femoral artery and the sac of the aneurysm.

Closure of an occlusion of the false aneurysm sac may be achieved by injection of thrombin into the sac of the aneurysm, duplex ultrasound-guided manual compression over the neck of the false aneurysm. Rarely, surgical repair may be required.

The report

A stenosis obstructing more than 50% of the arterial lumen would be expected to result in reduced flow down the artery and angina, whereas a short lesion less than 50% of the diameter of the arterial lumen would not be considered flow-limiting.

Stenoses are therefore graded as a percentage narrowing or classified as mild (50%–75%), moderate (76%–90%), severe (91%–99%) or blocked (100%) according to a visual examination of the angiogram.

Coronary artery disease and symptoms

Surprisingly, there is a poor correlation between symptoms and coronary artery disease. A patient with severe triple-vessel coronary artery disease may be symptom free until the occurrence of a myocardial infarct. Conversely, a patient with very mild disease may have very troublesome angina. This paradox highlights the importance of treating the patient in conjunction with the angiographic result and other clinical and investigative information, rather than only the angiogram.

Possible treatment strategies

41214313Medical treatment is advised when there is no need for revascularisation based on symptoms or coronary angiographic findings, or in the uncommon situation when revascularisation by either angioplasty or coronary artery surgery is not feasible or is too risky.

Coronary artery bypass surgery is generally advised in patients who are unsuitable for coronary angioplasty, which is equally effective in relieving angina.

Repeat revascularisation is more likely to be required in patients who have had angioplasty, because of the risks of restenosis, which are lower with the use of stents and particularly coated stents.

Coronary artery surgery is preferred to angioplasty in patients with severe triple-vessel coronary artery disease and left ventricular impairment, because it confers the added advantage of improving prognosis as well as symptoms.

Dr Clive Handler is consultant in pulmonary hypertension at the Royal Free Hospital, London

Dr Gerry Coghlan is consultant cardiologist at the national pulmonary hypertension unit, Royal Free Hospital, London

This article is based on a chapter in Management of Cardiac Problems in Primary Care by Dr Clive Handler and Dr Gerry Coghlan, published by Radcliffe, which is offering a 20% discount to Pulse readers (usual price £29.95 + p&p, offer price £23.96 + p&p). To claim, order via www.radcliffe-oxford.com or by telephone on 01235 528820. Please quote discount code ‘Pulse'. Offer expires 31 May 2009.

Patient information Patient information

Some patients find the test uncomfortable, but most are anxious about the implications of a result showing obstructive coronary artery disease.
Injection of local anaesthetic into the skin over the femoral artery may sting, and injection of contrast into the left ventricle may cause a feeling of flushing and occasionally nausea.
Passage of a catheter in the aorta is painless unless the aorta is dissected by the catheter tip, which is very rare.
The patient should be warned by the operator about the recognised complications (one in 1,000 risk of stroke, myocardial infarction and death), which are more common in patients with atheromatous disease in the aorta.
To avoid the risk of bleeding, the patient should not drive, cycle or participate in sports for at least 24 hours after the angiogram.
The result and the probable management plan should be explained to the patient before they go home, although the final management plan is often decided at a later department cardiothoracic meeting

Catheterisation provide better information than non-invasive imaging Catheterisation provide better information than non-invasive imaging Complications indications

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