B P3 C21 Coronary Angiography and Intravascular Imaging Flashcards
(135 cards)
Class 1 indications for CA in SIHD
Patients with SIHD who have survived sudden cardiac death or potentially life-threatening ventricular arrhythmia.
Patients with SIHD who develop symptoms and signs of HF
Patients whose clinical characteristics and results of noninvasive testing indicate a high likelihood of severe IHD
Patients with presumed SIHD who have unacceptable ischemic symptoms despite optimal medical therapy
Class I indications for CA in UA and NSTEMI
- An urgent/immediate invasive strategy (diagnostic angiography with revascularization if appropriate) is indicated in patients with NSTE- ACS who have refractory angina or hemodynamic or electrical instability (without serious comorbidities or contraindications to such procedures). (LOE: A)
- An early invasive strategy (diagnostic angiography with revascularization if appropriate) is indicated in initially stabilized patients with NSTE-ACS (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events. (LOE: B)
Class I indications for CA in STEMI
- Immediate angiography and PCI when indicated should be performed in resuscitated out-of-hospital cardiac arrest patients whose initial ECG shows STEMI. (LOE: B)
- Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours’ duration. (LOE: A)
- Primary PCI should be performed in patients with STEMI and ischemic symptoms of less than 12 hours’ duration who have contraindications to fibrinolytic therapy, irrespective of the time delay from first medical contact. (LOE: B)
- Primary PCI should be performed in patients with STEMI and cardiogenic shock or acute severe HF, irrespective of time delay from MI onset. (LOE: B)
Risk Factors That Support Early Invasive Evaluation of Patients Presenting with ACS
Significant troponin increase
Diagnostic ST or T wave changes
GRACE score >140
Diabetes mellitus
Reduced LV function (ejection fraction <40%)
Early postinfarction angina
Recent PCI
Prior CABG
Intermediate to high GRACE risk score
During injection of contrast media into the right coronary artery (RCA), one should take care to avoid deep cannulation of the RCA and injection of contrast media directly into the _____________ because this can result in ______________
Conus branch
Ventircular fibrillation
There are ___ absolute contraindications to coronary angiography listed in the clinical practice guidelines. However, specific conditions should be taken into account when weighing risks and benefits of the procedure.
No
Relative contraindications that should be taken into account are _____.
Known anaphylactoid reaction to contrast media
Moderate to severe kidney impairment
Decompensated heart failure and pulmonary edema that prevent the patient from lying down during the procedure
Uncontrolled hypertension
Active infection
Coagulopathy
Gastrointestinal bleeding
Pregnancy
Complications during coronary angiography are rare, occurring in approximately ___% of patients, with serious complications such as cerebrovascular accident (CVA), or stroke, or myocardial infarction (MI) accounting for less than _____% of all patients. Mortality rate is lower than 0.1%
2%
1%
Although rare, the most common complications of coronary angiography are _____.
Allergic reactions to contrast
Vascular complications
Worsening of kidney function
The risk of a vascular complication increases with the _____.
Diameter of the sheath used
Age of the patient
Degree of local calcifications
Embolic events are rare but can occur and may involve the coronary arteries, central nervous system, or peripheral arteries. _____ arteries can increase the likelihood of embolization.
Highly calcific axillary or subclavian
In addition, _____ have been reported as risk factors for periprocedural stroke
Advanced age
Diabetes mellitus
Emergency coronary angiography
Prior stroke
Renal failure
Congestive heart failure (CHF)
Use of ________ access rather than femoral access has significantly reduced the rate of vascular and bleeding complications
Radial
CI-AKI is defined as an acute deterioration of renal function, defined as an increase in creatinine of ________ or more or ___________ compared with baseline. It generally develops ______________ after administration of an intravascular contrast agent in the absence of other identifiable causes
0.5mg/dl
25% or greater
24 to 72 hours
Risk of CI-AKI depends largely on ____________________
Components of Mehran risk score
Baseline renal function (eGFR value below 60 mL/min are at high risk of CI-AKI)
CHF (5 points),
Hypotension (IABP)(5 points),
Age > 75 years (4 points),
eGFR (2-4 points), DM (3 points), Anemia (3 points),
Contrast volume (1 point/100cc)
Prevention of CI AKI
Periprocedural hydration with crystalloids, 1-1.5 mL/kg/hr 3-12 hours before and 12-24 hours after the procedure of hydration volume adjusted as per LVEDP
Prefer IOCM/LOCM
Minimize volume of CM
Periprocedural statin treatment (rosuvastatin?)
Radiation injury may be deterministic (i.e.-_______________), which can present weeks after exposure, or _______________, which is genetically determined and not dosedependent.
Dose-dependent
Stochastic
Deterministic injury may result in skin injury, hair loss, and lens injury. However, the most common location of radiation-induced lesions in cardiac catheterization is the skin of the _____, and common patterns include erythema, telangiectasia, and plaques
Back
Exposure to radiation can be minimized in several ways:
(1) Reduced FT and acquisition time
(2) Use of multiple angles rather than a single working camera position
(3) Reduced fluoroscopy dose
(4) Avoidance of high magnification
(5) Use of collimator beams and filters
(6) Avoidance of high angulation
(7) Reduction in the flat-panel image detector as much as possible
For exposures of absorbed radiation greater than 5 Gy, patients should be advised to watch for areas of _____; for those greater than 10 Gy, a _____t should be consulted to calculate the peak dose in 2 to 4 weeks; greater than 15 Gy is regarded as a _____. Similarly, in the event that FT exceeds 60 minutes, physicians must be vigilant for late radiation effects.
> 5 Gy: Erythema
> 10 Gy: Medical physicist consult
> 15 Gy: Hospital risk management event
Access site for femoral artery insertion
Landmark
Common femoral artery (CFA) is punctured with a base-metal needle approximately 1 cm below the inguinal line with a 45- to 60-degree angulation
Head of the femur
Usually, a 6 French (6F) sheath (French units: F = ____ mm) is used for coronary angiography and coronary interventions
1F = 0.33 mm
The _____ is performed by applying pressure on both the ulnar and the radial artery of one wrist to occlude them while the patient keeps the hand elevated with the fist clenched for approximately 30 seconds.
Once opened, the hand appears pale. The compression on the ulnar artery is then removed while pressure is maintained on the radial artery.If the ulnar artery supply to the hand is adequate, the color quickly returns to the hand and the test is normal. Conversely, if color does not return, the ulnar artery supply is insufficient, meaning that the radial artery supports the entire circulation of the hand. In this case the radial artery should not be punctured, because this may compromise the blood flow to the hand
Modified Allen test
This rule (Modified Allen Test) may be bypassed if an oximeter is placed in the thumb during radial artery occlusion, and resurgence of pulsation and oxygenation is documented after its initial disappearance _____.
“Barbeau method”