Download Indication and contra-indications for cardiac catheterization

Indication and contra-indications
for cardiac catheterization
PUMCH
Shen zhujun
Cardiac catheterization
For diagnosis
• Left heart cath.(inclu. CAG) : from artery, use
a catheter to measure left cardiac chamber
and large vessel pressure or CAG or blood
gas measurement.
• Right heart cath. : from vein, use a catheter to
measure the pressure, angiogram or blood
gas sample, EP test or cardiac biopsy.
Coronary angiogram
For stable angina or ischemia
without symptom
• AP CCS III or IV on medication (B)
• No matter the degree of AP, non-invasive test
show high risk* (A)
• Aborted cardiac death, sustained VT (≥30sec) or
non-sustained (<30sec) polymorphic VT (B)
High-risk CAD (annual death
>3%) on non-invasive test
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Severe LV dysfunction rest (LVEF< 35%)
High-risk on treadmill test (≤-11)
Severe LV dysfunction on exertion (LVEF< 35%)
Large area ischemic defect on stress test (esp.
anterior wall, Dobutamine or the others)
• Multiple ischemic segment on sress test
For non-cardiac surgery assess
the risk with know or suspect
CAD
• High risk with non-invasive test (C)
• Angina refractory to medication (C)
• Unstable angina, esp. moderate or high risk
surgery (C)
• Undetermined with non-invasive test with high
risk clinical risk factors before high risk surgery
(C)
For valve patient
• Adult valve patient with symptom need surgery
or balloon therapy, non-invasive test suggest
ischemia (B)
• After middle age (male 45, female 50) with some
risk factors without symptom before surgery (C)
• Infective endocarditis with evidence of coronary
embolism (C)
For heart failure patient
• CHF with systolic dysfunction with angina or
segmental wall motion abnomality or any
evidence of reversible ischemia (B)
• Before heart transplantation (C)
• CHF duo to MI with ventricular aneurysm or any
mechanical complication (C)
For STEMI --- indication
I
• Suitable for primary or rescue PCI– within 12 hrs
or over 12 hrs with persistent ischemia, cathlab
facility needed (A)
• Cardiogenic shock need revascularization– 36
hrs from onset or 18 hrs after shock (A)
• Complicated with VSD or severe MR need repair
(B)
• Complicated with persistent hemodynamic
unstable or electrical unstable condition (C)
For STEMI --- contra-indication
III
• Multiple co-morbidities, revascularization may
not help the patient (C)
For UA/STEMI --- indication
• Recurrent ischemia after medication (B)
• Moderate or High risk：TIMI score≥3.
Age≥65yrs; ≥3 CAD risk factors; Known CAD;
Aspirin in past 7 days; Recent (within 24hrs)
severe angina; ST deviation≥0.5mm; cardiac
markers elevation (A).
• Low risk but non-invasive test show high risk：
EF<0.35、large area ischemia (esp. anterior
wall) or multiple segment ischemia (B)
• UA post-PCI or CABG (C)
• Prinzmetal angina (C)
For UA/STEMI --- contraindication
III
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Multiple co-morbiditis, cannot benefit from
revascularization (C)
Chest pain with low risk UA (C)
Not a candidate for revascularization (C)
For recent MI --- indication
• Any ischemic evidence on low level stress test
(B)
Relative contra-indication
• Unknow fever or fever not controlled
• Severe or acute liver or renal dysfunction or
failure
• Severe anemia
• Severe electrolyte disturbance
• End stage carcinoma
• Aortic valve IE
• Severe bleeding disease or active bleeding
Relative contra-indication (Cont’)
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stroke (acute phase)
Digoxin intoxication
CHF not controlled
Severe coagulation disease
Patient can’t co-operate
Any disease or condition make the patient can’t
benefit from revascularization therapy
Factors increase the risk of CAG
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age> 70 yr
Complicated congenital heart disease
Severe obesity
Cachexia
Uncontrolled hyperglycemia
Hypoxia
Severe COPD
CRF
Hyperthyroidism
Factors increase the risk of CAG
(cont’)
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Triple vessel disease
Left main disease
Heart failure, grade IV
Severe mitral valve 、aortic valve disease or after
mechanical valve replacement
LVEF< 35 ％
High risk on treadmill test (with hypotension or
severe ischemia)
Pulmonary hypertension
PCWP> 25 mm Hg
Factors increase the risk of CAG
(cont’)
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Coagulation or bleeding disturbance
Uncontrolled hypertension
Severe peripheral artery disease
Recent stroke
Severe aortic insufficency
LV-gram indication
• Routine LV-gram should be done before or after
CAG to evaluate the left ventricular function,
mitral valve and aortic valve function
• LV was not done regularly in daily practice
because the advantage of Echocardiography
LV-gram Contra-indication
• LV thrombus
• Severe LV dysfunction, LVEDP≥20mmHg
R-cath. Indication
• Complicated congenital heart disease
need anatomical and physiological
assessment.
• Congenital heart disease complicated with
pulmonary hypertension
• EP test
• Cardiac biopsy
R-cath. Contra-indication
• Simple cases can be accurately diagnosed
by echocardiography or other non-invasive
procedures