TASK 1: RESEARCH ON THE DIFFERENT CARDIOVASCULAR MANAGEMENTS: CURRENT TRENDS IN THE

MANAGEMENT OF CARDIOVASCULAR DISORDERS

CARDIAC CATHETERIZATION
OVERVIEW

Cardiac catheterization (cardiac cath or heart cath) is a medical procedure that cardiologists, or
heart specialists use to evaluate how well your heart is working. It is used to diagnose and treat certain
cardiovascular conditions. A long thin tube called a catheter is inserted in an artery or vein in your groin,
neck or arm and threaded through your blood vessels to your heart with the aid of a special X-ray
machine. Doctors use contrast dye that they inject into your blood vessels through the catheter to
create X-ray videos of your valves, coronary arteries, and heart chambers. Some heart disease
treatments, such as coronary angioplasty and coronary stenting, also are done using cardiac
catheterization. Usually, you’ll be awake during cardiac catheterization but will be given medications to
help you relax. Recovery time for a cardiac catheterization is quick, and there’s a low risk of
complications. Cardiac catheterization is performed in a hospital by a cardiologist and a team of doctors,
nurses, technician, and other medical professionals.

WHO IS A CANDIDATE FOR CARDIAC CATHERIZATION?

Your doctor may order a cardiac catheterization if you are exhibiting signs of heart disease such
as:

 Chest pain
 Pain or pressure in the shoulders
 Pressure or pain in the shoulders, arms, jaw, neck or back
 Shortness of breath
 Other reasons why your doctor may recommend a cardiac catheterization include:

 Evaluate chest pain on a patient recovering from a recent heart attack

 Evaluate severe heart attack that caused major tissue damage
 Evaluate abnormal electrocardiogram results that indicate heart disease
 To look for problems with heart valves
 To view the shape of your heart and the heart chambers inside it to identify heart defects
prior to heart surgery
 To measure oxygen and blood flow in the heart as well as evaluate how artificial heart
valves are functioning

PURPOSE

Cardiac catheterization is done to see if you have a heart problem. It can also be done as part of
a procedure to correct a known heart problem. If you’re having cardiac catheterization as a test for
heart disease, your doctor can:

 Check the pumping function of your heart (right or left ventriculogram)

 Diagnose heart defects present from birth (congenital heart defects)
 Locate narrowing or blockages in your blood vessels that could cause chest pain (angiogram)
 Look for problems with your valves
 Measure pressure and oxygen levels in different parts of your heart (hemodynamic
assessment)
 Take a sample of tissue from your heart (biopsy)

Cardiac catheterization is also used as part of some procedures to treat heart disease. These
procedures include:

 Closing holes in the heart and fixing other congenital defects

 Closing off part of your heart to prevent blood clots
 Opening narrow heart valves (balloon valvuloplasty)
 Repairing or replacing heart valves
 Treating irregular heart rhythms with ablation
 Widening a narrowed artery (angioplasty) with or without stent placement

WHO SHOULD NOT HAVE CARDIAC CATHETERIZATION?

Your doctor may wait to do the procedure or recommend that you do not have cardiac
catheterization if you have one of the following conditions:

 Abnormal electrolyte levels in your blood

 Acute gastrointestinal bleeding
 Acute kidney failure, or sever kidney disease that is not being treated with dialysis
 Acute stroke
 Blood that is too thin from medicines such as warfarin or other causes
  High blood levels of a heart medicine called digoxin
 Previous severe allergic reaction to the dye that is used during cardiac catheterization
 Severe anemia, which is a lower than normal red blood cell count or hemoglobin
 Unexplained fever
 Untreated infection

RISKS

As with most procedures done on your heart and blood vessels, cardiac catheterization has
some risks. Major complications are rare, though. Your doctor will discuss the risks with you and be
careful to lessen the chances of having them. Risks of cardiac catheterization are:

 Air embolism- when air gets into your blood vessel

 Allergic reactions to the dye or medication
 Bleeding at puncture site
 Blood clots
 Bruising- some develop bruises where the catheter had been inserted (puncture site).
 Damage to the artery, heart or the area where the catheter was inserted
 Heart Attack
 Infection
 Irregular heart rhythms (arrhythmias)
 Kidney damage from the dye
 Perforation – a hole going through your blood vessel
 Stroke

PREPARATION OF THE PATIENT FOR THE PROCEDURE

 ALLERGIES: Please discuss all your allergies with your doctor, especially those listed below.
o IVP Dye/Contrast Agent
o Iodine, Shellfish
o Latex/ Rubber Products
o Medicines like Penicillin
 BLOOD WORK: Ask your physician if all of the required pre-procedure test have been
completed or are scheduled before the cardiac catheterization procedure.
 CHEST X-RAY: For pre-procedure evaluation
 DIET: Don’t eat or drink anything for at least 6-8 hours before the procedure, or as directed
by your doctor. Having food or drink in your stomach can increase your risk of complications
from anesthesia. Ask your doctor or nurse if you should take your medications with small
amount of water. If you have diabetes, ask for instructions about diabetes medications and
insulin. You will usually be able to have something to eat and drink soon after the
procedure.
 ECG: Pre procedure patient’s evaluation
  MEDICATIONS: Discuss your medications with your physician. Your doctor may recommend
you to stop or adjust the doses several days prior to or on the day of the procedure,
especially those listed below.
o Anticoagulant medications that may thin your blood, such as warfarin, aspirin,
apixaban, dabigatran and rivaroxaban.
o Diabetes Medications such as Insulin
o Supplements
o It’s best if you take the original bottles so that your doctor will know the exact dose
you take. Don’t stop taking your medicine until your doctor tells you to.
 WHAT TO BRING :
o Bring with you your assistive device. If you usually wear a hearing aid, wear it
during the procedure. If you wear glasses, bring them to your appointment.
o Bring with you a family member. Have someone to wait with you before and after
the procedure.
o Bring with you a robe to wear. Bring a comfortable, easy to fold clothing
o Bring with you other personal belongings. You may be admitted to the hospital
after the procedure, so pack toiletries and any other items you would like to make
your stay more comfortable. Please leave valuables at home or with a family
member

HOW THE PROCEDURE IS PERFORMED

Cardiac catheterization is usually performed in the hospital. Cardiac catheterization is done in a

procedure room with special X-ray and imaging machines. Cardiac catheterization laboratory is a sterile
area. Procedure is usually performed while you’re awake but sedated. However, certain procedures,
such as ablation, valve repair or valve replacement, may be performed while you’re under general
anesthesia. A cardiac cath procedure usually takes about 30 minutes and longer if you have an
intervention, but the preparation and recovery time add several hours.

 Before the procedure:

o You’ll put on a hospital gown.
o You’ll also be asked to empty your bladder.
o You’ll have your blood pressure and pulse checked.
o You’ll be ask to give list of medications and dosages.
o You’ll be ask for any allergy.
o You’ll need to remove dentures and jewelry, especially necklaces that could
interfere with pictures of your heart.

 During the procedure:

o A nurse will put an IV (intravenous) line into a vein in your hand or arm so you can
get medicine (sedative) to help you relax, but you’ll be awake and a ble to follow
instructions during the procedure. You will also have monitors (electrodes) placed
on your chest to check your heartbeat during the test.
o Nurse or technician will clean and shave the hair from the site where the catheter
will be inserted. This is usually in the groin area. Other sites can be neck or arm.
Sterile cloths will cover the site and help prevent infection. Keep your arm on your
sides, under the sterile drapes.
o A local anesthetic is usually given to numb the needle puncture site. You may feel a
quick, stinging pain before the numbness sets in.
o After you feel numb, a small cut is made to access an artery. The doctor will make a
needle puncture through your skin and into a large blood vessel. A small straw-sized
tube (called a sheath) will be inserted into the vessel. The doctor will gently guide a
catheter (a long, thin tube) into your vessel through the sheath. A video screen will
show the position of the catheter as it is threaded through the major blood vessels
and to the heart. You may feel some pressure but you shouldn’t feel any pain.
o Threading the catheter shouldn’t be painful, and you won’t feel it moving through
your body. Tell your doctor or nurse if you have any discomfort.
o When the catheter is in place, they’ll dim the lights and insert a small amount of dye
(also called contrast material) through the catheters into your arteries and heart
chambers. The contrast material outlines your vessels, valves, and chambers.
o When the doctor injects the dye into your heart, you may feel hot or flushed. This is
normal and will go away in a few seconds. Tell the doctor or nurse if you feel itching
or tightness in your throat, nausea, chest discomfort, or any other symptoms.
o Various instruments may be placed at the tip of the catheter. It include instruments
to measure the pressure of blood in each heart chamber and in blood vessels, take
blood samples from different parts of the heart, or remove a tissue sample (biopsy)
from inside the heart.
o When a catheter is used to inject a dye that can be seen on X-rays, the procedure is
called Angiography.
o When a catheter is used to clear a narrowed or blocked artery, the procedure is
called Angioplasty or a Percutaneous Coronary Intervention (PCI).
o When a catheter is used to widen a narrowed heart valve opening, the procedure is
called Valvuloplasty.
o The X-ray camera will take photographs of your arteries and heart chambers. If
you’re awake during the procedure, you may be asked to take deep breaths, hold
your breath, cough or place your arms in various positions throughout the
procedure. Your table may be tilted at times, but you’ll have a safety strap on to
keep you on the table. You’ll need to hold your breaths while they’re taking the X-
rays.
o When all the photos are done the doctor will remove the catheters and the sheath
and turn on the lights. Your nurse will put pressure on the site to prevent bleeding.
Sometimes a special closure device is used.
MANAGEMENT/CARE OF THE PATIENT AFTER THE PROCEDURE

 Monitor patient for several hours in a recovery room after the procedure while the
anesthesia wears off. Check patient’s heartbeat, blood pressure and other vital signs during
recovery.
 Apply pressure to the puncture site to stop the bleeding.

 If the catheter was inserted in the arm, the doctor will remove it and the sheath.
o The puncture site will be closed and bandaged. Keep arm straight for at least an
hour. Inform patient that he/she will be able to walk around.
o Observe patient for a few hours to monitor any symptoms or side effects of the
procedure.
o Instruct patient to tell doctor or nurse if he/she thinks there is bleeding or feel any
numbness or tingling in his/her arm.

 If the catheter was inserted at the groin, doctor will remove the device and close the cut
with stitches, a collagen seal, or pressure.
o A collagen seal is a protein material that works with the body’s natural healing
processes to form a clot in the artery. In some situations, the doctor might stitch the
introducer sheath into place and take it out after the bleeding stops.
o To prevent infection, the wound will be covered with a sterile dressing.
o Instruct patient to lie flat and keep his/her leg straight for 2-6 hours to prevent
bleeding.
o To avoid straining of abdomen and groin, instruct patient to keep the head low (no
more than two pillows high) and won’t be able to sit up or stand during this time.
o The nurse will check the bandage regularly, but remind patient to tell if he/she
thinks there is bleeding (have a wet, warm sensation) or if toes tingle or feel numb.
o Give medication as doctor’s order to help with patient’s discomfort after the
anesthetic wears off.
o The doctor will order when patient can get out of bed to go to the bathroom. The
nurse will help patient sit up and dangle his/her legs on the side of the bed.
o Instruct patient to drink plenty of liquids to clear the dye out of your body.
o Inform patient that it is normal to feel the need to pee more often than usual.
Prepare bedpan or urinal if patient didn’t get a urinary catheter and unable to get
out of bed.

 Explain to patient to report any swelling, pain or bleeding at the puncture site, or if he/she
have any chest pain.
 The doctor will tell if patient can go home or will need to stay overnight. The length of stay
in the hospital will depend on patient’s condition. Patient may be able to go home the same
 day as the catheterization, or may need to stay overnight or longer if he/she have an
additional procedure, such as angioplasty and stent placement.
 Before patient leaves the hospital, instructions will be given about what to do at home.
Treatment, including medications, diet and future procedures, will be discussed with you
prior to going home. Care of the wound site, activity and follow-up care will also be
discussed.

 Things to do after you got home:

o Carefully follow all instructions. It is important to take your medications as directed
by your doctor and to make follow up appointments before leaving the hospital
o Most people can return to their normal activities the day after the procedure
depending on whether any additional interventions were done during the cardiac
cath.
o A small bruise at the puncture site is normal. If the site starts to bleed, lie flat and
press firmly on top of it for a few minutes. Then, recheck to see if the bleeding has
stopped.
o Call the doctor if: Your leg, arm or neck with the puncture becomes numb or tingles,
or feels cold or turns blue. The area around the puncture site looks more bruised.
The puncture site swells or fluids drain from it.

RESULTS FROM CARDIAC CATHETERIZATION

If your doctor performed the cardiac cath as a diagnostic test, your doctor will review your
results with you after the sedation wears off.

If the procedure reveals you have a narrowed or blocked artery, you may need an immediate
PCI with or without stent placement. If there are multiple blockages, you may need open-heart surgery
called coronary bypass surgery. If your doctor suspects you may need an emergency procedure during
the cardiac catheterization, he or she will discuss the various options with you before the procedure
begins.
 CORONARY ANGIOPLASTY
OVERVIEW

Angioplasty is a medical procedure that opens up a blocked or narrowed artery around the
heart. It is a standard treatment for narrower or blocked arteries in this area of the body. It is also called
Percutaneous Coronary Intervention or PCI. It is a procedure wherein surgeon inserts a tube into an
artery in the groin or wrist. They then thread the tube toward the affected artery around the heart.
Finally, they insert a balloon or stent (metal tube) to open the artery. Doctors use live X-rays and a
contrast dye to guide the catheter and assess the arteries they need to treat. Compared with heart
surgery, angioplasty is a minimally invasive as it does not involve opening up of the chest.

In the term angioplasty, “angio” means blood vessel, and “plasty” is opening up. In PCI, the P
stands for percutaneous or “through the skin” while coronary refers to the location of blood vessels
around the heart. Angioplasty is a conventional treatment for coronary heart disease (CHD) and heart
attacks (acute coronary syndrome). These conditions are a buildup of plaque, or atherosclerosis, on the
walls of the arteries. As plaque accumulates, the arteries narrow and can become blocked. In a heart
attack, the plaque may rupture, spilling cholesterol into an artery, potentially leading to a clot that stops
blood flow.
TYPES OF CORONARY ANGIOPLASTY

There are two main types of angioplasty:

 Balloon Angioplasty- involves using the pressure of an inflating balloon to clear plaque that
is blocking an artery. This is rarely done alone except in cases when done alone except in
cases when doctors are unable to place a stent in the required position
 Stent placement in the artery- involves a tube or stent, made out of wire mesh. Stents help
to prevent an artery narrowing again after angioplasty. Stents may be made of bare metal or
have a coating of medication when they include medication, they are called drug eluting
stents (DES) and are less likely to plug up again. DES are now used almost exclusively with
very little use of bare metal stents.

WHO IS A CANDIDATE FOR CORONARY ANGIOPLASTY?

You may be a good candidate for angioplasty, if you have a significant narrowing or blockage of
a coronary artery, or you have symptoms of CAD. Doctors often use angioplasty and related procedures
to prevent a heart attack. Your doctor may recommend angioplasty if:

 You have chest pain or shortness of breath due to CAD.

  You have significant narrowing or blocking of only 1 or 2 coronary arteries. Your doctor may
recommend heart bypass surgery (coronary artery bypass graft surgery) instead of
angioplasty.
 You have had a heart attack
 You are not feeling better despite medicines and lifestyle changes to reverse atherosclerosis
 You have a coronary bypass graft that has closed or narrowed

PURPOSE

Doctors may recommend angioplasty to:

 Improve blood supply to the heart muscle during or after a heart attack
 Increase blood flow to the heart
 Reduce chest pain, or angina
 Support more activity for people with chest pain
 Treat an abnormal stress test

WHO SHOULD NOT HAVE CORONARY ANGIOPLASTY

You should not have angioplasty if:

 You have mild to moderate narrowing of the arteries and no symptoms.

 Your condition is responding well to medicine and lifestyle changes.
 People with kidney disease or reduced kidney function may not be good candidates for
angioplasty.

RISKS

On the whole, angioplasty is a safe procedure without complications. Although complications

from angioplasty are rare, they can include:

 An allergic reaction to the dye

 Arrhythmia, or abnormal heart rhythm-during the procedure, the heart may beat too
quickly or too slowly. These heart rhythm problems are usually short-livd, but sometimes
medications or a temporary pacemakers is needed.
 Blockage that requires an emergency bypass
 Blood clot- blood clots also form in catheters and travel to the brain if they break loose.
 Chest pain
  Damage to kidneys- the dye used during angioplasty and stent placement can cause kidney
damage, especially in people who already have kidney problems. If you’re at increased risk,
your doctor may take steps to try to protect your kidneys, such as limiting the amount of
contrast dye and making sure that you’re well hydrated during the procedure
 Death
 Heart attack- though rare, you may have a heart attack during the procedure
 Prolonged bleeding from the catheter insertion site in the groin or wrist
 Stroke- during angioplasty, s stroke can occur if plaques break loose when the catheters are
being threaded through the aorta.
 Tear or damage to artery or major blood vessel- your coronary artery may be torn or
ruptured during the procedure. These complications may require emergency bypass surgery

Other individuals have a higher risk of complications from angioplasty, as do those with the
following conditions:

 Chronic kidney disease

 Heart disease
 Several blocked arteries

There is also a chance of the artery becoming blocked with plaque again through a process
called restenosis, plaque shift, or stent thrombosis, which is a clot in the stent.

PREPARATION OF THE PATIENT FOR THE PROCEDURE

Angioplasty is a minimally invasive procedure, but it is still surgery, and people must follow their
doctor’s instructions carefully beforehand. Before a scheduled angioplasty, your doctor will review your
medical history and do a physical exam.

 ALLERGIES: Please discuss all your allergies with your doctor, especially those listed below.
o Contrast Dye/Contrast Agent
 BLOOD WORK: Ask your physician if all of the required pre-procedure test have been
completed or are scheduled before the cardiac catheterization procedure.
 CHEST X-RAY: Pre procedure patient evaluation
 DIET: Patient may need to avoid stop eating or drinking 6-8 hours before the procedure.
 ECG: To evaluate patient before procedure.
 KIDNEY TEST: To evaluate kidney function, as the contrast dye that the surgeons use can
affect it.
 MEDICATIONS: Patient need to inform their doctor about any medications and supplements
they are taking. In some cases, they may need to stop takings some drugs before the
procedure, especially those listed below:
o Aspirin
o Blood Thinners
o NSAIDS

HOW THE PROCEDURE IS PERFORMED

 According to the American Heart Association, angioplasty can take anywhere from 30 minutes to
a few hours. The person may need to stay in hospital overnight. Angioplasty can be done in an
emergency setting such as a heart attack. Or it can be done as elective surgery if your doctor strongly
suspects you have heart disease.

 Before the procedure:

o Your healthcare team will explain the procedure and you can ask questions.
o You will be asked to sign a consent form that gives your permission to do the
procedure.
o You’ll put on a hospital gown.
o You’ll also be asked to empty your bladder.
o You’ll have your baseline vital signs checked.
o You’ll be ask to give list of medications and dosages, including nitroglycerin, if you
take it
o Tell your healthcare team if you are sensitive to or are allergic to any medicines,
latex, tape, and local or general anesthesia.
o Tell if you have any body piercings on your chest or abdomen, pacemaker or other
implanted device.
o Remove any jewelry or other objects that may interfere with the procedure.
o Patient will be placed on the procedure table.
o Patient will be connected to an ECG monitor that records the electrical activity of
the heart and monitors heart rate, blood pressure, breathing rate and oxygen level
during the procedure.

 During the procedure:

o An intravenous (IV) line will be placed in your arm to give you fluids and medicines.
The medicine will relax you and prevent blood clots from forming. Theses medicines
may make you feel sleepy or as though you’re floating or numb. A strong
antiplatelet medicines are given through the IV to prevent blood clots from forming
in the artery or on the stent.
o The area where the catheter will be inserted, usually the arm or groin (upper thigh),
will be shaved.
o The shaved area will be cleaned to make it germ-free and then numbed. Local
anesthesia will be injected into the skin at the insertion site. The numbing medicine
may sting as it’s going in.
o When the patient is comfortable, the doctor will begin the procedure. You will be
awake but sleepy.
o A small cut is made in the arm or groin into which a tube called a sheath is put.
o The doctor then threads a very thin guide wire through the artery in the arm or
groin toward the area of the coronary artery that’s blocked.
 o The doctor puts a long, thin, flexible tube called a catheter through the sheath and
slides it over the guide wire and up to the blockage. He or she takes out the guide
wire once the catheter is in the right spot.
o A small amount of dye may be injected through the catheter into the bloodstream
to help show the lockage on X-ray. This x-ray picture of the heart is called an
angiogram. You may feel some effects when the contrast dye is injected into the IV
line. These effects include a flushing sensation, a salty or metallic taste in the
mouth, or a brief headache. These effects usually last only a few moments.
o Observe patient for any breathing trouble, sweating, numbness, itching, nausea or
vomiting, chills, or heart palpitations.
o The doctor slides a tube with a small deflated balloon inside it through the catheter
and into the coronary artery where the blockage is.
o When the tube reaches the blockage, the balloon is inflated. The balloon pushes the
plaque against the wall of the artery and widens it. This helps to increase the flow of
blood to the heart. Patient may have some chest pain or discomfort at this point
because blood flow is temporarily blocked by the inflated balloon. Any chest
discomfort or pain should go away when the balloon is deflated. However, notify
doctor if you notice any continued discomfort or pain.
o The balloon is then deflated. Sometimes the balloon is inflated and deflated more
than once to widen the artery. The doctor will take measurements, pictures, or
angiograms after the artery has been opened. Once it has been determined that the
artery is opened sufficiently, the catheter will be removed.
o In some cases, plaque is removed during angioplasty. A catheter with a rotating
shaver on its tip is inserted into the artery to cut away hard plaque. Lasers also may
be used to dissolve or break up the plaque.
o If the doctor needs to put a stent (small mesh tube) in your artery, another tube
with a balloon will be threaded through the artery. A stent is wrapped around the
balloon. The doctor will inflate the balloon, which will cause and pulled out of the
artery with the tube. The stent stays in the artery.
o After the angioplasty is done, the doctor pulls back the catheter and removes it and
the sheath. The hole in the artery is either sealed with a special device, or pressure
is put on it until the blood vessels seals.

MANAGEMENT/CARE OF THE PATIENT AFTER THE PROCEDURE

 When angioplasty is complete, the cardiologist explain to patient that soreness, bruising,
and possibly bleeding are common around the area where catheters entered the body.
 Monitor patient’s vital sign. Typically, a patient will recover in the hospital for a few hours or
overnight before going home.
 Check catheter insertion site for bleeding.
 If the insertion was in the groin, patient will not be allowed to bend leg for several hours.
 If the insertion was in the arm, arm will be kept elevated on pillows nd kept sraiaght by
placing the arm in an arm guard.
  Remind patient that they must not drive as they may still have sedative medications in their
system.
 Remind patient to follow doctor’s advice when he/she can return to work. Patient can often
return to work within a week, but their doctor will advise on how active they can be and
when.
 Instruct patient on follow up visit to the doctor after angioplasty to evaluate recovery, adjust
medications and develop an ongoing treatment plan for their cardiovascular health.
 Things to do after you got home:
o Drink plenty of fluids to help flush your body of the contrast dye.
o Avoid strenuous exercise and lifting heavy objects for at least a day afterward. Ask
your doctor or nurse about other restrictions in activity.
 Call the doctor if: catheter insertion site is bleeding or swelling, pain and discomfort
develops, experience redness, swelling, drainage or fever (signs of infection), sudden change
in temperature or color of the leg or arm that was used for the procedure, you feel weak
and develop chest pain or shortness of breath.

RESULTS FROM CORONARY ANGIOPLASTY

Coronary angioplasty greatly increases blood flow through the previously narrowed or blocked
coronary artery. Your chest pain generally should decrease, and you may be better able to exercise.
Having angioplasty and stenting doesn’t mean your heart disease goes away. You’ll need to continue
healthy lifestyle habits and take medications as prescribed by your doctor. Successful angioplasty also
means you might not have to undergo coronary artery bypass surgery, a more invasive procedure that
requires longer recovery time.

If you experience symptoms similar to those you had before your procedure, such as chest pain
or shortness of breath, contact your doctor. If you have chest pain at rest or pain that doesn’t respond
to nitroglycerin, call for emergency medical help.

To keep your heart healthy after angioplasty, you should:

 Quit smoking
 Lower your cholesterol levels
 Eat a healthy diet that is low in saturated fat
 Maintain a healthy weight
 Control other conditions, such as diabetes and high blood pressure
 Get regular exercise
 Take medications as prescribed by the doctor