Heart cath procedure

Heart cath (also called angiogram) precisely measures pressures inside the heart and pulmonary arteries, EF, and the amount of plaque build-up in arteries. We are talking about diagnostic cath - not angioplasty. In angioplasty, catheter-based tools are used to clear blockages out of your arteries. A diagnostic cath is used to spot blockages, and take measurements. It is also the way doctors obtain samples of heart tissue for study, called biopsy.
     Unfortunately, many doctors consider a cath mandatory whenever a cardiomyopathy diagnosis is made. For that reason and because no cardiac catheter procedure is without risk, I suggest you seriously question your doctor about the exact reasons he ordered this test for you, just to be sure the information gained is worth the risk.

Diagnostic Cath

This "procedure" consists of your cardiologist inserting a long, thin tube (catheter) into a blood vessel through a small incision in your groin. The tube is guided to your heart, where the coronary arteries begin. Dye is injected into your coronary artery and is seen on the x-ray monitors as white lines. Where that white line is interrupted or disturbed, an area of plaque build-up inside the wall of the artery is indicated. High speed x-ray cameras record the dye's movement during the procedure.
     Dye will also be injected into your heart's pumping chambers to see how well the your heart pumps and how well your heart valves work. Pressure measurements are also taken at this time and are interpreted by your cardiologist with the aid of a computer.

Taking The Test

cath lab camera and tableYou may be asked not to eat or drink anything after midnight the day before your cath. About one hour before the procedure, you may be given a mild sedative to help you relax, but not put you to sleep. If you want that sedative, you should be very assertive about it. Some cath labs do not routinely give a sedative and others are not too good about following your doctor's orders for one. Be firm about it (jump off the gurney and run down the hall in your gown screaming Fire! if necessary) and you'll get one. <g> You do need to be awake for the cath so you can change positions, breathe in deeply at times, and cough when the doc tells you to cough.
     cathPlease note that instead of inserting the catheter into an artery through your groin, another method is now available, where the catheter is threaded through the radial artery in your wrist. Read about it here, here or here. Before they cart you off to the lab, you'll be asked to shave one side of your groin, in the crease right where your thigh connects to your torso. They may reshave this once you get in the cath lab.
     You will be asked not to wear your underwear. In just a hospital gown, you will be wheeled to the cath lab on a gurney. There, you'll be moved onto a table surrounded by high tech medical machinery. Nurses will "paste" EKG electrodes on your chest and will shave and clean your groin with an antiseptic solution. They will cover most of you with sterile towels. When the doctor arrives, he will inject your groin with a numbing medication. In many cases, this will not be your actual cardiologist but someone who specializes in invasive procedures at that hospital, so don't be surprised if he's not your doctor. Introductions are in order, though. <g> This is an interventional cardiologist, often called an "operator."

After the local anesthetic has numbed your groin, the doctor will make a small puncture and insert the catheter into your blood vessel there. You shouldn't feel any pain at all, but there will be a sense of pressure which is rather unpleasant but bearable. He will be watching the catheter's movement on the x-ray monitors. You can also watch and the clarity of the pictures is excellent. You won't feel the catheter inside you as it moves up your artery to your heart. Once the heart is reached, dye is injected through the catheter.
cathYou may have dye injected several times during your cath and the catheter may be moved around during the procedure. This allows for different views of your heart and arteries. When they pump dye into your heart to take pictures of it, you'll get a tremendous flushed feeling, accompanied by a deep warmth and maybe tingling. This shouldn't last very long (maybe 30 to 60 seconds) and is par for the course - not something to get too worried about unless it doesn't go away. You may also feel like urinating and may, in fact, do exactly that without being able to help it. Don't be embarrassed; this is neither unexpected nor unusual.
     If you get dizzy, sick to your stomach, feel numb anywhere but your groin or if you have chest pain, the doctor needs to know immmediately. One nurse should be focused on your face during the whole procedure and make no mistake, he has power in that lab. If you have any of these symptoms, or get upset or scared, you tell him and don't hold back - he has that job because he is no-nonsense and knows how to take charge. He will be sure the doc is aware of your problem.
     Once the cath is done, the catheter will be removed. You shouldn't feel this either, except for some pressure. A nurse will apply very firm pressure over the incision in your groin for at least 10 minutes. She will really be leaning on the bandage she has over your incision, so expect this to be uncomfortable, but it should be bearable. She'll then put a large dressing over your incision and you'll be wheeled back to your hospital room. Your time in the cath lab itself should be no more than one hour.

Back In Your Hospital Room

When you are back in your room, they will move you back to your bed. You'll have to lie flat in bed for 4 to 6 hours so the puncture site can heal enough not to bleed. Different hospitals use different methods at this point. Some place a small sandbag over your incision to apply pressure and prevent bleeding. Some actually put a clamp over the incision that clamps you to the bed to apply pressure and prevent bleeding. That's considered a bit medieval now, though. <g>
     Although some staff still require you to lay completely flat, most should allow you to elevate your torso a bit for comfort and ease of breathing. You can eat and drink normally again now if they'll let you be slightly elevated but you will have to use a bedpan or urinal for taking care of business. You'll have your vital signs and the incision checked often for the first few hours.
     After the required 4 to 6 hours has passed, you will have the sandbag or clamp removed and will be allowed to move around, although you should still take it very easy so you don't open that incision. Your doctor should discuss with you the results of the cath within 24 hours.
     Please note that recently the Angio Seal device has been put into use. You may receive it. This is a device that takes the place of all that pressure and lying flat stuff. It is basically a "plug" that seals the incision (cut) in your groin where the catheter went in. You can read about it here and here. The FDA released a warning letter about such devices in October of 1999 and you can read it here.

Some Possible Side Effects

You will have a bruise at the incision point. You will probably also feel a hard lump there. The bruise will probably get worse for a day or two afterward. Both are normal and should disappear in about two weeks. You may develop a backache and a whole slew of sore muscles and aches and pains from lying flat for too long but eventually they will fade away. You may also come away with a bad headache. If so, please contact your doctor immediately so it can be gotten rid of - there's no such thing as "necessary" pain.
     Now, don't panic at this paragraph, but it is something you should know. Cath is an invasive procedure and all invasive procedures are like surgery - there is definite risk involved. About 2 people out of every 1000 that have a cath die as a result. You can help minimize that risk yourself by selecting a medical center that does a lot of caths every year (high volume). Also select a cardiologist who does a lot of caths every year. That means hundreds of caths every year! This really does reduce your risk. See this page for more information. You also want to go to a large hospital doing lots of caths so they will have the facilities to handle an emergency it one happens. See this page.
     Right heart caths (Swan-Ganz) are done through the jugular in your neck, are more dangerous, and may not provide enough information to justify the added risk for people with left-sided heart failure. They may be necessary for right heart failure or other conditions or complications. They are also considered necessary for heart transplant recipients.

How To Make It Easier

Because hospitals in general and cath labs in particular are very cold, I suggest you ask for a blanket or two to use whenever they aren't actually doing the procedure. Ask for the blankets before you leave your hospital room so you'll be sure to get them before you get cold. As usual, don't take those diuretics too close to test time because believe me, they aren't going to let you up to go pee during this one. <g>

Radial Cath Trial 

Jon's note: Several women have posted to The Beat Goes On that radial artery (arm/wrist) cath is riskier for women due to their smaller artery diameter.

Using the transradial cath procedure is a recent development. We did a randomized trial in which 99 patients had groin access cath and 101 had radial (arm) cath for diagnostic purposes. Quality of life was measured at study start, at one day, and again at one week. Patients were also examined then for complications. Costs were also measured.
     There were no major complications due to choice of cath access site. One patient in the groin-cath group had a minor stroke. Radial cath reduced average length of stay: 3.6 hours for arm cath versus 10.4 hours for groin cath. For the first day after the procedure, measures of bodily pain, back pain and walking ability were better in the radial group. This was also true for the week following the procedure.
     There was a strong patient preference for radial cath as well. Radial reduced bed, pharmacy, and total hospital costs: $2010 for radial cath versus $2299 for groin cath.

Long version

In the United States, more than 1.1 million heart caths are done each year. Usually heart cath is done through the femoral artery in the groin. However, radial cath may reduce discomfort, shorten stay and lower costs. Bed rest is not required after a radial cath.
     We randomly assigned patients to groin or radial cath. Stable patients who were not expected to need other procedures were recruited. We studied quality of life, patient preference, and cost.
     All patients referred for diagnostic cardiac cath were screened. They were excluded for vascular disease that would prevent the preferred access, unstable symptoms, or need for additional procedures during the same hospital stay. Patients were not excluded for age, sex, body size, or race. They were randomly assigned by coin toss to either groin or radial cath.
     At one day and at one week after cath, a standard physical exam was done. Quality of life was measured in all patients before cath and at one day and at one week after cath. Quality of life was measured with the Medical Outcomes Study Short Form: a 36 item questionnaire and a series of specific questions. The procedure-specific questions cover overall discomfort, back pain, ability to use the bathroom, ability to feed or care for oneself, walking, pain at the access site and preference for cath method. Doctors doing the caths had to have done at least 50 radial caths before participating. They also had to have extensive experience doing groin access caths.
Groin caths After the procedure, catheters and sheaths were removed at the earliest possible time and bleeding was stopped with manual compression. Five to six hours of bed rest was enforced after that. Patients walked around for one hour after the bed rest period, then were discharged. Same-day discharge was encouraged.
Radial caths Cath was done through the nondominant arm if possible. After the procedure, the sheath was removed and a pressure bandage immediately applied to the puncture site without a period of manual pressure. The dressing was left in place until the following morning. Patients remained at upright bed rest for the first hour, were allowed to walk around for one more hour, and then were discharged. Same-day discharge was encouraged.
Economics Costs were calculated from a commercial hospital accounting system. Hospital cost data were collected and 4 areas of cost were measured:

  1. bed costs, including nursing use
  2. cath lab costs
  3. pharmacy costs
  4. all other costs

End points were patient preference, quality of life, and cost. To see whether having had both kinds of cath access before had any influence on patient preference, preference was also studied in patients who had been through both methods before (22% of patients). Almost a thousand patients were screened for this study. The most frequent causes for exclusion were unstable symptoms (384 patients) and planned additional procedures (103 patients). Both groups were well matched.
Results Procedures were successful in all patients, although one patient in the groin cath group and 2 in the radial group had to switch to the other access site. There were no major bleeding complications in either group. One patient in the groin cath group had a stroke immediately after the procedure. No other significant complications occurred.
     There were 5 patients - 3 in the groin cath group and 2 in the radial - who had angioplasty in the one-week follow-up period. All were done successfully from the same access site. Average length of stay was shorter in the radial group (3.6 hours versus 10.4 hours for the groin cath group).
Quality of life Quality of life scores were obtained in all 200 patients. One day after the procedure, body pain, social function, mental health, overall discomfort, back pain, ability to use the bathroom, and walking ability were better in the radial group. During the week after the procedure, physical function, social function, mental health, role limitations as the result of physical health, bodily pain, overall discomfort, back pain, and walking ability were better in the radial group. There was no difference in pain at the catheter insertion site.
Patient preference At both one day and one week, most patients preferred the radial method. Among the 44 patients who had experienced both methods, the radial method was strongly preferred in 80% and moderately preferred in 7%, with only 2% preferring groin cath.
Cost Cath lab costs were equal in the 2 groups. Bed and pharmacy costs were significantly lower with radial cath. The cost of other services was ony slightly lower with radial cath. The overall effect was a significant reduction in average hospital cost with radial cath: $2010 versus $2299 for groin cath.

Discussion Heart cath is usually done through the femoral artery at the groin. This may result in problems with blood vessels in the leg, sometimes serious. To reduce that risk, bed rest is required after the catheter is removed. Complications from enforced bed rest of 6 hours or more can be worse in the elderly and in patients with previous back pain. Radial artery cath has several potential advantages. The radial artery is easily compressed and has many collateral blood vessels, reducing risk of vascular complications.
     Patients can walk around immediately following the procedure. Body and back pain were less over the week after the procedure. Also, there was a strong patient preference for the radial method. Although preference - measured in all patients - favored radial cath, patients who had both methods were undoubtedly best able to determine the merits of each approach. That 80% of patients who had been through both strongly preferred radial cath and only 2% preferred groin cath is significant.
     The shorter hospital stay after radial cath reduced overall costs by nearly $300 (14%) per patient. A low complication rate was expected because the study only included stable patients. In the radial group, no patient had loss of the radial pulse, which would indicate blockage of the radial artery. This may be the result of high-dose heparin use.
 
Title: Effect Of Transradial Access on Quality of Life and Cost of Cardiac Catheterization: A Randomized Comparison
Authors: Christopher Cooper MD, Reda El-Shiekh MD, David Cohen MD MSc, Linda Blaesing RN, Mark Burket MD, Asish Basu MD, Joseph Moore MD
Source: Am Heart J 138(3):430-436, 1999

Updated June 12, 2004

All information on this site is opinion only. All concepts, explanations, trials, and studies have been re-written in plain English and may contain errors. I am not a doctor. Use the reference information at the end of each article to search MedLine for more complete and accurate information. All original copyrights apply. No information on this page should be used by any person to affect their medical, legal, educational, social, or psychological treatment in any way. I am not a doctor. This web site and all its pages, graphics, and content copyright © 1997, 1998, 1999, 2000, 2001, 2002, 2003, 2004 Jon C.

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