Synonym/Acronym
Angiography of heart, angiocardiography, cardiac angiography, cardiac catheterization, cineangiocardiography, coronary angiography, coronary arteriography.
Rationale
To visualize and assess the heart and surrounding structure for abnormalities, defects, aneurysm, atherosclerosis, and tumors.
Patient Preparation
There are no activity restrictions unless by medical direction. Instruct the patient to fast and restrict fluids for 2 to 4 hr, or as ordered, prior to the procedure. Fasting may be ordered as a precaution against aspiration related to possible nausea and vomiting. The American Society of Anesthesiologists has fasting guidelines for risk levels according to patient status. More information can be located at www.asahq.org. The Canadian Anesthesiologists’ Society has fasting guidelines for preprocedural fasting. Related information can be located at https://www.cas.ca/English/Page/Files/97_Appendix%206.pdf.
Note: Protocols regarding the use of iodinated contrast medium in patients with impaired kidney function and who are receiving metformin or drugs containing metformin for type 2 diabetes may vary by facility; the drug may be discontinued on the day of the test and continue to be withheld for 48 hr after the test. Kidney function should be assessed per facility protocol before use of metformin is resumed (e.g., Cr, eGFR, hydration or clinical assessment).
Regarding the patient’s risk for bleeding, the patient should be instructed to avoid taking natural products and medications with known anticoagulant, antiplatelet, or thrombolytic properties or to reduce dosage, as ordered, prior to the procedure. Number of days to withhold medication is dependent on the type of anticoagulant. Note the last time and dose of medication taken. Protocols may vary among facilities.
Normal Findings
- Normal great vessels and coronary arteries.
Normal Adult Hemodynamic Pressures and Volumes Monitored During Coronary Angiography (Cardiac Catheterization)
| Pressures | Description of What Measured Parameter Represents | Normal Value |
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| Arterial blood pressure (also known as routine blood pressure) | The pressure in the brachial artery; one of the significant vital signs, it reflects the pressure the heart exerts to pump blood through the circulatory system | Systolic (90–120) mm Hg/diastolic (60–80) mm Hg | | Mean arterial pressure (MAP) | The average arterial pressure of one cardiac cycle; considered a better indicator of perfusion than routine blood pressure but obtainable only by direct measurement during cardiac catheterization | 70–105 mm Hg | | Left ventricular pressures | Peak pressure in the left ventricle during systole/peak pressure in the left ventricle at the end of diastole; indication of contractility of the heart muscle | Systolic (90–140) mm Hg/diastolic (4–12) mm Hg | | Central venous pressure (CVP); also right atrial pressure (RAP) | The right-sided ventricular pressures exerted by the central veins closest to the heart (jugular, subclavian, or femoral); used to estimate blood volume and venous return | 2–6 mm Hg | | Pulmonary artery pressure (PAP) | The pressures in the pulmonary artery | Systolic (15–30) mm Hg/diastolic (4–12) mm Hg | | Pulmonary capillary wedge pressure (PCWP); also pulmonary artery occlusion pressure (PAOP) | The pressure in the pulmonary vessels; used to provide an estimate of left atrial filling pressure, to provide an estimate of left ventricle pressure during end diastole, and as a way to measure ventricular preload | 6–12 mm Hg | | Volumes | Description of What Measured Parameter Represents | Normal Value | | Cardiac output | The amount of blood pumped out by the ventricle of the heart in 1 min | 4–8 L/min | | Cardiac index | The cardiac output adjusted for body surface to provide the index, which is a more precise measurement; used to assess the function of the ventricle | 2.8–4.2 L/min/m2 | | Arterial oxygen saturation | The concentration of oxygen in the blood | 95%–100% | | Stroke volume (SV) | The amount of blood pumped by each ventricle with each contraction in a heartbeat | 60–90 mL/beat | | Stroke volume index (SVI) | The stroke volume adjusted for body surface to provide the index, which is a more precise measurement | 33–47 mL/m2 | | Ejection fraction (EF) | Stroke volume expressed as a percentage of end diastolic volume | 55%–70% |
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Study type: X-ray, special/contrast; related body system: Circulatory system.
Angiography allows x-ray visualization of the heart, aorta, inferior vena cava, pulmonary artery and vein, and coronary arteries after injection of iodinated contrast medium through a catheter; cardiac pressures and volumes are recorded through the same catheter. The insertion site for a right heart catheterization is into a peripheral vein, usually the femoral, brachial, or subclavian vein. The insertion site for a left heart catheterization is into an artery, usually the femoral, radial, or brachial artery. Fluoroscopy is used to guide catheter placement, and angiograms (high-speed x-ray images) provide images of the heart and associated vessels, which are displayed on a monitor and are recorded for future viewing and evaluation.
Digital subtraction angiography (DSA) is a computerized method of removing undesired structures, such as bone, from the surrounding area of interest. A digital image is taken prior to injection of the contrast and then again after the contrast has been injected. By subtracting the preinjection image from the postinjection image, a higher-quality, unobstructed image can be created. Patterns of circulation, cardiac output, cardiac functions, and changes in vessel wall appearance can be viewed to help diagnose the presence of vascular abnormalities or lesions. Pulmonary artery abnormalities are seen with right heart views, and coronary artery and thoracic aorta abnormalities are seen with left heart views. Coronary angiography is useful for evaluating cardiovascular disease and various types of cardiac abnormalities.
Coronary angiography, more commonly called cardiac catheterization, is a definitive test for coronary artery disease (CAD). CAD is a condition in which the blood vessels to the heart lose their elasticity and become narrowed by atherosclerotic deposits of plaque. Significant blockage is treatable using coronary artery bypass grafting (CABG) surgery. Cardiac catheterization can also be used in conjunction with less invasive interventional alternatives to CABG surgery, such as percutaneous transluminal coronary angioplasty (PTCA), with or without placement of stents.
PTCA is also known as balloon angioplasty because once the blockage is identified and determined to be treatable, a balloon catheter is used to help correct the problem. The balloon in the catheter is inflated to compress the plaque against the sides of the affected vessel. The balloon may be inflated multiple times and with increasing size to increase the diameter of the vessel’s lumen, which restores more normal blood flow. A stent, which is a small mesh tube, may be placed in the affected vessel to keep it open after the angioplasty is completed. For additional information regarding screening guidelines for atherosclerotic cardiovascular disease (ASCVD), which includes coronary artery disease (CAD), refer to the study titled “Cholesterol, Total and Fractions.”
Applications of Cardiac Catheterization for Infants and Pediatric Patients : Cardiac catheterization is very useful in identification of the type of heart defect, determination of the exact location of the defect, and indications regarding the severity of the defect. Some of the common operable heart defects in infants and children include repairs for ventricular septal defects, atrial septic defects, tetralogy of Fallot, valve defects, and arterial switches. Cardiac catheterization can also be used as a palliative procedure prior to arterial switch repair. The catheterization, called a balloon atrial septostomy, is used to create a small hole in the inner wall of the heart between the atria that allows a greater volume of oxygenated blood to enter the circulatory system. The improved quality of circulating blood provides some time for very young patients to gain strength prior to the surgical repair. The hole is closed when the corrective surgery is completed.
Contraindications
Pregnancy is a general contraindication to procedures involving radiation.
Conditions associated with adverse reactions to contrast medium (e.g., asthma, food allergies, or allergy to contrast medium). Although patients are asked specifically if they have a known allergy to iodine or shellfish (shellfish contain high levels of iodine), it has been well established that the reaction is not to iodine; an actual iodine allergy would be problematic because iodine is required for the production of thyroid hormones. In the case of shellfish, the reaction is to a muscle protein called tropomyosin; in the case of iodinated contrast medium, the reaction is to the noniodinated part of the contrast molecule. Patients with a known hypersensitivity to the medium may benefit from premedication with corticosteroids and diphenhydramine; the use of nonionic contrast or an alternative noncontrast imaging study, if available, may be considered for patients who have severe asthma or who have experienced moderate to severe reactions to ionic contrast medium.
Patients with moderate to marked renal impairment (glomerular filtration rate less than 30 mL/min/1.73 m2), or with conditions associated with preexisting renal insufficiency (e.g., chronic kidney disease, single kidney transplant, nephrectomy, diabetes, multiple myeloma, treatment with aminoglycosides and NSAIDs), because iodinated contrast is nephrotoxic.
Patients with moderate to marked renal impairment (glomerular filtration rate less than 30 mL/min/1.73 m2) and who are also taking metformin, which may put them at risk for development of drug-induced lactic acidosis, a dangerous and sometimes fatal adverse effect of metformin (related to renal impairment that does not support sufficient excretion of metformin).
Patients who are chronically dehydrated before the test, especially older adults and patients whose health is already compromised, because of their risk of contrast-induced acute kidney injury.
Patients with pheochromocytoma, because iodinated contrast may cause a hypertensive crisis.
Patients with bleeding disorders or receiving anticoagulant therapy, because the puncture site may not stop bleeding.
Factors That May Alter the Results of the Study
- Gas or feces in the gastrointestinal tract resulting from inadequate cleansing or failure to restrict food intake before the study.
- Retained barium from a previous radiological procedure; barium studies should be performed more than 4 days before angiography.
- Metallic objects (e.g., jewelry, body rings) within the examination field, which may inhibit organ visualization and cause unclear images.
- Inability of the patient to cooperate or remain still during the procedure, because movement can produce blurred or otherwise unclear images.
Abnormal Findings Related to
Areas where the contrast medium was not able to circulate will appear dark against the normally white blood vessels and vascular areas of cardiac tissue.
Potential Nursing Problems: Assessment & Nursing Diagnosis
| Problems | Signs and Symptoms | | Cardiac output (decreased—related to anomalies, dissection, occlusion, plaque, rupture, tumors) | Altered level of consciousness, anxiety, cool skin, delayed capillary refill, diaphoresis, diminished peripheral pulses, hypotension, increased pulse that may be thready, restlessness | | Pain (related to aneurysm, dissection, inflammation, injury, obstruction, trauma, tumor) | Self-report of pain, moaning; crying, restlessness; anxiety; increased heart rate; increased blood pressure; guarding | | Tissue perfusion (inadequate—related to inadequate arterial blood flow secondary to rupture, bleeding, dissection) | Capillary refill 3 sec or longer; cool extremities, pallor; cyanosis; mottling; limited motor function; sensation loss; hypotension |
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Before the Study: Planning and Implementation
Teaching the Patient What to Expect
- Discuss how this procedure can assist with assessment of cardiac function and assess for heart disease.
- Explain that the procedure takes about 30 to 60 min and is usually performed in a radiology or vascular suite.
- Review the procedure with the patient.
- Explain that prior to the procedure, laboratory testing may be required to determine the possibility of bleeding risk (coagulation testing) or to assess for impaired kidney function (serum Cr or eGFR) if use of iodinated contrast medium is anticipated.
- Explain that pregnancy testing may be required.
- Discuss how reducing health-care-associated infections is an important patient safety goal, and a number of different safety practices will be implemented during the procedure.
- Explain that hair in the area near the catheter insertion site may be clipped and the area cleaned with an antiseptic solution to cleanse bacteria from the skin in order to reduce the risk for infection.
- Discuss how there may be moments of discomfort or pain when the IV line or catheter is inserted allowing for infusion of fluids such as saline, anesthetics, sedatives, medications used in the procedure, or emergency medications.
- Explain that contrast medium will be injected, by catheter, at a separate site from the IV line.
- Advise that a burning and flushing sensation may be felt throughout the body during injection of the contrast medium, and there may be an urge to cough, flushing, nausea, or a salty or metallic taste.
Procedural Information
- Policies regarding breastfeeding before and after an imaging procedure may vary among facilities. For additional information see Appendix A: Patient Preparation and Specimen Collection, subsection: Potential Contraindications and Complications Associated with Diagnostic Procedures.
- Note: The World Health Organization, Centers for Disease Control and Prevention, and Association of periOperative Registered Nurses recommend that hair not be removed at all unless it interferes with the incision site or other aspects of the procedure because hair removal by any means is associated with increased infection rates.
- Hair removal requires facilities to use a protocol that is based on scientific literature or the endorsement of a professional organization.
- Clipping immediately before the procedure and in a location outside the procedure area is preferred to shaving with a razor.
- Shaving creates a break in skin integrity and provides a way for bacteria on the skin to enter the incision site.
- Baseline vital signs are recorded and monitored throughout the procedure.
- Electrocardiographic electrodes are placed for cardiac monitoring to establish a baseline rhythm and identify any ventricular dysrhythmias.
- Peripheral pulses are marked with a pen before the venography, allowing for a quicker and more consistent assessment of the pulses after the procedure.
- Positioning for this procedure is in the supine position on an examination table.
- The selected site is cleansed and covered with a sterile drape.
- A local anesthetic is injected at the site, and a small incision is made or a needle is inserted under fluoroscopy.
- Once contrast medium is injected, a rapid series of images is taken during and after the filling of the vessels to be examined.
- Delayed images may be taken to examine the vessels after a time and to monitor the venous phase of the procedure.
- Instructions are given to the patient to inhale deeply and hold their breath while the x-ray images are taken, and then to exhale.
- The patient is advised to take slow, deep breaths if nausea occurs during the procedure.
- An ordered antiemetic drug is administered as needed.
- An emesis basin is ready for use as needed.
- Once the study is completed, the needle or catheter is removed, and a pressure dressing is applied over the puncture site.
Potential Nursing Actions
Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.
- Glucagon or an anticholinergic drug may be given to stabilize movement of the stomach muscles; peristaltic contractions (motion) may alter study findings.
- Investigate the presence of other risk factors, such as family history of heart disease, smoking, obesity, diet, lack of physical activity, hypertension, diabetes, previous myocardial infarction (MI), and previous vascular disease.
- Knowledge of genetics assists in identifying those who may benefit from additional education, risk assessment, and counseling.
- Genetics is the study and identification of genes, genetic mutations, and inheritance. For example, genetics provides some insight into the likelihood of inheriting a medical condition such as CAD.
- Genomic studies evaluate the interaction of groups of genes. The combined activity or combined expression of groups of genes allows assumptions or predictions to be made. As an example, genomic studies measure the levels of activity in multiple genes to predict how they, along with environmental and lifestyle decisions, influence the development of type 2 diabetes, CAD, MI, or ischemic stroke. Further information regarding inheritance of genes can be found in the study titled “Genetic Testing.”
Safety Considerations
- Anticoagulants, aspirin, and other salicylates should be discontinued by medical direction for the appropriate number of days prior to a procedure where bleeding is a potential complication. Note the last time and dose of medication taken.
After the Study: Implementation & Evaluation Potential Nursing Actions
Avoiding Complications
- Monitor the patient for complications related to the procedure.
- Establishing an IV site and injection of contrast medium are invasive procedures that can cause rare complications. For additional information see Appendix A: Patient Preparation and Specimen Collection, subsection: Potential Contraindications and Complications Associated with Diagnostic Procedures.
- Observe/assess the needle/catheter insertion site for bleeding, inflammation, or hematoma formation.
- Administer ordered antihistamines or prophylactic steroids if the patient has an allergic reaction.
- Assess extremities for signs of ischemia or absence of distal pulse caused by a catheter-induced thrombus.
Treatment Considerations
- Follow post-procedure vital sign and assessment protocol.
- Discuss resuming the usual diet, fluids, medications, or activity, as directed by the HCP.
- Monitor peripheral pulses as well as changes in the color or temperature of the skin around the insertion site that may be indicative of bleeding.
- Maintain bedrest in supine position to prevent stress on the puncture site for 2 to 6 hr, depending on the location of insertion site.
Cardiac Output
- Facilitate management of decreased cardiac output.
- Provide IV fluid to support blood pressure (rapid rate as appropriate) or blood transfusion as ordered.
- Monitor and trend vital signs, heart rate, blood pressure, and respiratory rate.
- Perform continuous ECG monitoring.
- Monitor for decreased urinary output, changes in level of consciousness, shortness of breath, cyanosis, pallor, and cool skin.
- Administer ordered oxygen and trend oxygen saturation with pulse oximetry.
Pain
- Assess pain character, location, duration, and intensity.
- Use an easily understood culture and age appropriate pain rating scale
- Place in a position of comfort.
- Administer ordered medications.
- Consider alternative measures for pain management (imagery, relaxation, music, etc.).
- Assess and trend vital signs.
- Facilitate a calm, quiet environment.
- Discuss pain management methods that work best for the patient.
Tissue Perfusion
- Facilitate management of inadequate tissue perfusion.
- Assess peripheral pulses for amplitude; use a doppler if needed.
- Mark peripheral pulses with a pen for quick identification and consistency of comparative evaluation.
- Assess for changes in peripheral sensations, tingling, numbness, coolness, cyanosis, mottling.
- Monitor kidney function with accurate intake and output.
- Evaluate for changes in motor function.
- Administer ordered blood, blood products, and other fluids to maintain circulatory homeostasis.
- Document vital signs frequently, noting B/P trends.
- Administer ordered medications to manage blood pressure.
Nutritional Considerations
- Note that nutritional therapy is recommended for those with identified CAD risk, especially for those with elevated low-density lipoprotein (LDL) cholesterol levels, other lipid disorders, diabetes, insulin resistance, or metabolic syndrome.
- Review ways to decrease intake of saturated fats and increase intake of polyunsaturated fats, with the inclusion of cultural considerations.
- Discuss limiting intake of refined processed sugar and sodium.
- Discuss limiting cholesterol intake to less than 300 mg per day.
- Encourage the intake of fresh fruits and vegetables, unprocessed carbohydrates, poultry, and grains.
- Advise those with elevated triglycerides to eliminate or reduce alcohol.
- Discuss ideal body weight and the purpose of and relationship between ideal weight and caloric intake to support cardiac health.
- Ensure consideration of cultural influences with dietary choices to better facilitate adherence to a change in lifestyle.
- Explain that a variety of dietary patterns are beneficial for people with CAD; for additional information regarding nutritional guidelines refer to the study titled “Cholesterol, Total and Fractions.”
- Discuss other changeable risk factors warranting education to include strategies to encourage regular participation of moderate aerobic physical activity three to four times per week, eliminate tobacco use, and adhere to a heart-healthy diet.
Clinical Judgement
- Consider ways to overcome barriers with adherence to lifestyle changes required to improve cardiac health.
Follow-Up and Desired Outcomes
- Acknowledges contact information provided for the American Heart Association (www.heart.org/HEARTORG), National Heart, Lung, and Blood Institute (www.nhlbi.nih.gov), the U.S. Department of Agriculture’s resource for nutrition (www.choosemyplate.gov), and Legs for Life (www.legsforlife.org).
- Understands that bedrest should be maintained at home for 4 to 6 hr after the procedure or as ordered and to apply cold compresses to the puncture site as needed to reduce discomfort or edema.
- Describes the correct process for the care and assessment of the site and the need to observe for bleeding, hematoma formation, and inflammation.
- Acknowledges the importance of adhering to the therapy regimen, and states significant adverse effects associated with the prescribed medication.
- Agrees to review corresponding literature provided by a pharmacist.