Mr. S, a 76-year-old retired truck driver, admitted with a diagnosis of congestive heart failure (CHF), is scheduled for diagnostic cardiac catheterization at 8 AM. After recovery in the holding area, he is expected to return to the telemetry unit. Mrs. D, a 68-year-old woman with known coronary artery disease, is scheduled for an angioplasty at 10 AM. She will go to the cardiac procedure recovery unit (CPRU) for specialized care following the procedure. While Susan makes rounds, Alan, an ED RN, cares for Mr. A, a 42-year-old schoolteacher who has unstable angina. This patient will need an emergency catheterization with possible intervention.

The National Center for Health Statistics reported that in 2004 there were 1,297,000 cardiac catheterizations, 615,000 angioplasties with stent insertions, and 664,000 balloon angioplasties or coronary atherectomies.¹ These procedures all involve physicians approaching blockages and lesions through the lumen of coronary arteries to restore coronary artery blood flow to the myocardium of the heart.²

Percutaneous coronary intervention (PCI) may include percutaneous transluminal coronary angioplasty (PTCA) (balloon dilation), atherectomy (plaque cutting and removal), thrombectomy (clot extraction), roto ablation (drilling and pulverizing of hard plaque), laser-assisted angioplasty (ablation of atherosclerotic plaques), and stent placements (“scaffolding” of interior lumens of diseased arteries). Stents are used in more than 90% of PCI procedures.² Coronary stents are made of metal, and some now deliver antiproliferative medication directly at the site. These drug-eluting stents are useful for lesions at high risk of thrombosis. Indications for PCI can be found in the 2007 Focused Update of the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention.³

Diagnostic catheterizations are usually performed via an 11 cm-long plastic sheath, which is usually 4F to 7F gauge that is inserted into the femoral artery for the introduction of catheters (See Table A: Indications for Cardiac Catheterization).⁴ Heparinized solutions may be used to maintain the catheter’s patency. Through the catheter, radiopaque contrast materials are injected into coronary arteries and the left ventricle to track coronary artery and ventricle-to-aorta blood flow. X-rays of the contrast flow are recorded on 35 mm cine film or on a computer disk (CD) to facilitate subsequent review of the anatomy and diagnosis of an abnormality.⁵

Radiopaque contrast exposes blockages or lesions, which may be treated with interventional procedures that use dilation balloons, roto ablation drills, or vacuum-extraction devices to restore circulation.⁶ Larger 6F to 8F arterial sheaths are used for PTCA and stent placement; and sheaths as large as 12F are used for atherectomy, thrombectomy, or roto ablation procedures.⁵ Clinicians insert a femoral vein sheath for fluid and drug administration and a temporary pacing catheter, when needed, which is advanced to the right ventricle.

In patients with compromised femoral arterial circulation and/or morbid obesity, percutaneous or surgical “cutdown” of the brachial or even radial artery may be used.⁴ Before arterial access is established, palpation or a Doppler device is used to evaluate pulses distal to the proposed site, to determine the appropriateness of the site and a baseline for postprocedure comparisons. If the radial approach is planned, Allen’s Test determines if the ulnar artery can provide adequate blood flow to the hand in the event of radial occlusion.⁷

Preparing for diagnostic cardiac catheterization

Susan interviews Mr. S and reviews his chart to determine his readiness for the 8 AM diagnostic cardiac catheterization procedure. She notes a record of his medical history and physical examination, signed procedure/operative consent, current lab study results, ECG, and chest X-ray. Baseline blood urea nitrogen (BUN) and creatinine levels have been obtained for later comparison with postprocedure values because iodinated radiopaque contrast could exacerbate preexistent renal insufficiency. Susan also reviews the baseline hemoglobin and hematocrit so she can monitor for changes that might indicate bleeding. She notes that the prothrombin (PT) and partial thromboplastin times (PTT), and the international normalized ratio (INR) are within normal limits. Elevated PT and PTT values would indicate the potential for increased risk of bleeding during or after the procedure and may cause the physician to delay the catheterization procedure. Oral anticoagulants should be withheld, and the INR should be less than 1.8 prior to the procedure to avoid increased risk of bleeding.⁴

Susan notices that the oral hypoglycemic, metformin hydrochloride (Glucophage), has been discontinued for 48 hours before the procedure; it will also be withheld for 48 hours after the procedure, and until the creatinine is stable, because this medication could cause renal failure if taken concomitantly with iodinated contrast material.⁸ Patients who have a documented allergy to contrast medium should receive prednisone or hydrocortisone 12 hours before and just before the procedure. Cimetidine and diphenhydramine may also be prescribed.⁴ Measures that can be taken to help reduce the incidence of contrast-induced neprophathy include adequate IV expansion with an isotonic crystalloid, and certain medications, such as theophylline/aminophylline, statins, ascorbic acid, and prostoglandin E1.⁸ Acetylcysteine, an antioxidant, can also be orally administered before the procedure to reduce the incidence of contrast media-induced nephropathy.⁹

An attendant completes Mr. S’s groin skin clipping preparation and Susan notes that the IV is patent during the preoperative assessment.

The physical assessment includes lung auscultation and evaluation of radial and pedal pulses, which are documented for later comparison. On the postprocedural clinical pathway record, Susan notes potential variations, such as shortness of breath, diaphoresis, pulse irregularities, or chest pain that might occur related to preexisting conditions of diabetes, allergies, and CHF.

Patient teaching

Despite seeing a patient education film and reading a preparation booklet, Mr. S. admits that he’s nervous. Studies have shown that patients undergoing cardiac catheterization develop feelings of anxiety and increased stress, which are the result of the unknown experience of the procedure and the uncertainty of the results.¹⁰ Susan knows that this anxiety could have an adverse effect on his recovery, so she holds his hand and acknowledges his feelings. She assures him that he will receive a medication in the lab to help him relax. She instructs his wife where to wait during the procedure, cautioning that delays could occur that might vary the waiting time, but that personnel would keep her updated regarding her husband’s progress.

Patient descriptions of cardiac catheterization range from “a piece of cake” to “worse than a root canal.” Some patients may perceive cardiac catheterization as a threat to one’s health status, and arousal of the autonomic (sympathetic) nervous system can elicit negative physiological and psychological human responses as a reaction to this perceived threat. A Canadian study investigated the fears and beliefs of patients regarding cardiac catheterization.¹¹ Findings from this study indicated that education should be provided close to the time of the procedure to reduce anxiety. Fears that were identified include medical complications, that family needs would not be met, and concerns about not knowing the catheterizing physician.¹¹ At a large urban medical center, researchers found that in patients admitted to the hospital for diagnostic cardiac catheterization (n = 46), a 20-minute back massage prior to the procedure appeared to reduce systolic blood pressure, while preparatory time in the cardiac catheterization laboratory appeared to reduce diastolic blood pressure, respiration, perceived psychological distress, and pain in those of the test group, as compared with those undergoing standard care.¹²

Nurses who take the time to ask patients to describe their feelings can individualize their instruction to help ease patients’ anxiety. Some patients may not want to be told everything, while others feel they need to know it all. While preparing patients for catheterization procedures, explaining sensations associated with them may relieve some anxiety by addressing their fears of the unknown.¹⁰ Nurses should inform patients that —

• The arterial access may be uncomfortable, but not painful. Although local anesthetic is always used, it stings.
• Back discomfort related to the flat procedure table is a common complaint, but analgesics and positioning with pillows can provide comfort.
• Patients can enhance their comfort by bringing pillows, wearing warm socks, and using their hearing aids and dentures.
• Someone — specifically, the “circulator” — will be assigned to meet the patient’s needs.
• Feelings of “fluttering” in the chest, caused by dysrhythmias and catheter manipulation, are common and expected.
• Chest pressure or angina from transient coronary ischemia caused by contrast administration into the coronary arteries may occur during angiograms, while a hot flush feeling may be experienced during an angiogram of the left ventricle. Chest discomfort should be reported so that medication, oxygen, or simply a “rest” period can be prescribed.
• Angina experienced during interventional procedures may be evaluated on a scale of one to 10 for possible treatment with narcotics, nitrates, and oxygen.
• Roto ablation therapy may produce vibrations and burning sensations due to friction from the device spinning in the coronary artery. “Drilling” sounds may be heard during atherectomy, embolectomy, and roto ablation procedures.

After Mr. S departs, Susan prepares Mrs. D for a coronary angioplasty. Her physical preparation is similar to that of Mr. S, but she needs more preoperative teaching preparation. However, the patient’s major concern is that her daughter, who has not arrived at the hospital, will not be able to find her after the procedure. Susan calls the patient information desk to make sure that hospital personnel will direct her daughter to the CPRU, and informs Mrs. D of the steps taken to ensure her daughter finds her.

Meanwhile, in the ED, as Alan prepares Mr. A for an emergency cardiac catheterization, the dispatcher announces the impending ambulance transfer of another man with chest pain. Alan knows that “time is muscle” and that time to reperfusion with percutaneous coronary intervention should not be longer than 90 minutes.  To see how your hospital does meeting this goal, visit www.hospitalcompare.hhs.gov.

Alan gathers several consents for Mr. A’s procedure because hospital policy mandates consents for intraaortic balloon insertion; intervention by angioplasty, atherectomy, and/or stent; administration of IV antiplatelet or thrombolytic drug therapy; and emergency coronary artery bypass surgery for all patients with unstable angina who go to the cath lab. Because Mr. A is so uncomfortable, his wife signs the documents and also receives most of the teaching. Assessment and preparation of Mr. A is similar to that of Mr. S, except a blood type and cross screen is added in case immediate bypass surgery is indicated, when blood might be required.

Care after diagnostic versus interventional procedures

Susan comes back from escorting Mrs. D to the catheterization lab to find that Mr. S has returned from his diagnostic procedure. “It was a piece of cake!” he says, smiling, as she walks into his room.

Susan initiates a standard assessment protocol of frequent, periodic assessments of her patient’s groin insertion sites, peripheral pulses, and vital signs. Assessing for hematomas or pseudoaneurysms, she is particularly vigilant for ecchymosis, bleeding, or swelling at the groin sites. She advises Mr. S to notify the nursing staff immediately, if they occur.^2,13,14 A pseudoaneurysm, which can develop after the arterial wall is punctured during the procedure, is a palpable, pulsatile mass of solidified blood outside of the vessel wall.^4,14 She also tells him that coughing, sneezing, or laughing could initiate bleeding. “Remember, Mr. S, first aid for bleeding is direct pressure,” Susan explains. She advises him to restrict his activities to bed for the next two and a half to three hours, elevating the head of the bed to 30 degrees only after one hour.^15,16,17 Immobilizing his leg, Susan offers a urinal and instructs Mr. S to increase his fluid intake today to assist his kidneys in excreting the contrast medium.

Compared to patients undergoing diagnostic catheterization, patients undergoing cardiac interventional procedures are at greater risk for complications due to the use of large-bore catheters and sheaths, prolonged placement of sheaths, and lengthy procedures.¹⁵ The use of anticoagulant, thrombolytic, and antiplatelet therapies; multiple invasive studies during the same hospitalization; and punctures from multiple attempts to access the common femoral artery are associated with greater potential for postprocedure bleeding complications.² The use of such antiplatelet therapies as the glycoprotein IIb/IIIa inhibitors, abciximab (Reopro), eptifibatide (Integrilin), and tirofiban (Aggrastat), during procedures is increasing. The resulting platelet inhibition, which lasts from four to 48 hours after the drug is discontinued (depending on the agent used), necessitates added post-procedural vigilance for vascular complications, such as rebleeding at the insertion site, hematoma formation, retroperitoneal bleeding, arteriovenous-fistula formation, arterial occlusion, nerve damage or neuropathy, and pseudoaneurysm formation.¹⁸

Although any of these complications need to be reported immediately to the physician who performed the procedure, hemostasis is a nurse’s first concern. A growing pulsatile mass or frank bleeding requires immediate direct pressure on the artery 2 centimeters above the site, until bleeding stops. Guided compression repair of pseudoaneurysm is now possible with the use of ultrasonography.¹⁴ Patients undergoing interventional procedures are also at risk for coronary restenosis and such related cardiac complications as myocardial infarction. Many patients return from the catheterization lab with mild chest discomfort, but any increase in chest pain needs the attention of the physician.

Most patients who have coronary interventional procedures transfer to specialized units postoperatively, where their cardiac status can be monitored. Sheaths may remain sutured in place until clotting times are normal, as indicated by a PTT or an activated clotting time (ACT) of 150 to 200 seconds. An alternate approach is the removal of the sheath in the catheterization lab, using a vascular sealing device to achieve hemostasis. Current approaches include collagen plugs (Vasoseal and Angio-seal) or suture-mediated closure devices (Perclose).¹⁹ Specially trained personnel are usually assigned to remove the sheath, keeping in mind that delayed sheath removal is dangerous.²⁰ Studies have revealed that sheaths should be removed before seven hours after insertion and that most sheaths can be removed within five hours of insertion.²⁰ In the event that bivalirudin (Angiomax) is used for anticoagulation, monitoring of ACTs is not necessary and sheaths can be safely removed two hours after discontinuation of this medication.²⁰

Sheath removal may produce vasovagal syncope, which is an exaggerated vasovagal response caused by the parasympathetic nervous system due to pain, fear, or tissue injury. The vasovagal response can occur during arterial access, venipuncture, or occasionally before anticipated painful procedures. The syndrome is characterized by pallor, diaphoresis, nausea, and hypotension, which are frequently preceded by, or accompanied by, bradycardia. If untreated, it can progress to loss of consciousness and shock.^21,22 Treatment consists of discontinuing nitrates, administering a fluid bolus, and placing the patient in a modified Trendelenburg position by elevating the legs 20 degrees. These measures enhance blood return to the heart and raise the blood pressure (BP). Atropine sulfate, 0.5 mg to 1.0 mg IV, may be given at five-minute intervals until the baseline BP is regained.²²

Follow-Up

Mrs. D had an angioplasty with stent insertion, which was placed after a coronary artery dissected with the balloon inflation. The stent provides a scaffold to maintain patency and blood flow. Mrs. D, who experienced severe chest pain during the procedure, is transferred to a critical care unit (CCU) with sheaths sutured in place and a pressurized heparinized saline solution infusing into a femoral arterial line to maintain patency. This flush line allows 3 mL/hr of the solution to flow automatically when the pressure bag is inflated to a level higher than the patient’s systolic pressure. An inline pressure transducer on the femoral arterial flush line also provides arterial waveform monitoring. A heparin drip is also infusing, as well as a nitroglycerin solution, which will continue postprocedure to help control chest discomfort associated with hypertension. The IV antiplatelet infusion initiated in the catheterization lab is also infusing. Her daughter learns from the CPRU nurses that Mrs. D went to the CCU, where her condition can be more closely monitored, and that she can see her mother 30 minutes after Mrs. D. returns to the unit.

Mrs. D is assigned to Leah, a CCU nurse who notes the postcardiac interventional procedure orders, as follows:

• Continue heparin and Integrilin for 24 hours
• Obtain platelet count four hours after discontinuing Integrilin
• Titrate nitroglycerin drip to maintain systolic BP less than 150 mm Hg
• Administer an oral analgesic for back discomfort
• Maintain bedrest until sheaths are removed, then
• Return the patient to routine post-sheath activity orders

The sheaths will be removed three to four hours after the heparin is discontinued if Mrs. D has no chest pain and her ACT results are within ordered parameters. An increase in chest pain is to be reported immediately to the cardiologist because angina may indicate thrombus formation, reocclusion, or restenosis of the coronary artery.

When the prescribed parameters are met, Leah makes arrangements for Joanne, a CPRU nurse certified in sheath removal, to discontinue the sheaths. After Joanne removes the sheath, pressure is applied to the groin site for the prescribed half hour. Sometimes sandbag-type weights are placed over the dressings, in lieu of manual pressure on the wound site. Leah, who has assisted femoral sheath removals on several occasions, observes for a vasovagal syncope response. Leah notes that Mrs. D is becoming pale and diaphoretic, and is complaining of nausea, symptomatic of the vasovagal syncope response. Joanne maintains pressure, while Leah turns off the nitroglycerin drip, increases the IV fluid rate, and elevates the patient’s legs with pillows. Atropine is on standby, but not required in this case, as Mrs. D responds quickly to accurate, timely assessment and immediate treatment.

Discharge instructions

Mrs. D was discharged to home directly from the CCU the next day. Her angina subsided and she did not have any vascular complications other than minimal ecchymosis at her groin. Upon questioning, Leah addressed patient concerns about the groin site condition and provided Mrs. D with verbal and written discharge instructions regarding the signs and symptoms of local and systemic infection, when to seek medical attention, how to recognize bleeding and what to do about it, prescription information, activity protocols, and her next medical appointment.

Mr. S went home on the same day of his procedure. Although his right coronary artery had been totally occluded, collateral circulation supplied that area of his heart. He was treated with medications. In addition to the postcatheterization discharge instructions, Susan discussed heart-healthy lifestyle changes with Mr. S.

Mr. A had triple coronary artery bypass surgery and stayed in the cardiovascular CCU for 24 hours. He was discharged home after five days, with five days of home care visits prescribed.

Technologies advance regularly in the catheterization lab, but they all involve gaining access to, and restoring, the arterial circulation of the heart. Advancing technologies generate challenges for the nurse providing patient care and instructions. For example, hemostatic-puncture closure devices achieve postprocedural hemostasis by the insertion of a collagen plug directly into or over the artery,19 replacing the application of manual pressure for 20 minutes. This may require revising your site- and dressing-care instructions for patients because some of these devices present additional complications, such as occlusion or stenosis of femoral arteries. Although puncture-closure devices allow position changes earlier during bedrest and provide greater comfort levels for patients, those with peripheral vascular disease or poor hygiene may not be candidates for these devices. A review of the literature revealed that three hours of bedrest post sheath removal does not increase complication rates.²³

Nurses in cardiovascular units and home care settings encounter patients undergoing invasive cardiac procedures. They are in a crucial position to assess and positively affect patient responses to these procedures. As nurses fine-tune their skills by remaining current in information and practice, they can improve patient outcomes.^10,23