All about heart procedures: EKG, Stress Tests, Echocardiogram, Coronary Angiogram, Holter Monitor
A coronary angiogram is a procedure that’s used to diagnose obstructive coronary artery disease. Spaghetti-like catheters are inserted through either your femoral artery (located in your groin) or radial artery (located on your wrists) and Xray contrast is used to highlight the lumen of your coronary arteries. They are performed by cardiologists.
Typical symptoms that may prompt a coronary angiogram:
- Angina / chest pain
- Heart attacks (ST Elevation Myocardial Infarction also known as STEMI; or non-ST Elevation Myocardial Infarction also known as NSTEMI)
- Jaw pain, neck pain, arm pain, or any discomfort with exertion without satisfactory explanation
- Worsening chest pain
- Congenital heart disease/heart defects
- Heart failure / symptoms of heart failure
- To evaluate trauma to the chest (to assure coronary arteries are not damaged)
- Preoperatively, prior to open heart surgery
- Preoperatively, prior to solid organ transplant
- Preoperatively, after an abnormal stress test
- Preoperatively, in preparation for valve surgery (aortic stenosis, mitral stenosis, aortic regurgitation, mitral regurgitation, tricuspid stenosis, pulmonic stenosis, tricuspid regurgitation, or pulmonic regurgitation)
Similar to other medical procedures, there always is a risk of adverse events with coronary angiograms. Since the commercialized use of the coronary angiogram back in the 80s, the procedure has become much safer.
The most common complication is vascular injury or bleeding from the access site. This occurs in approximately 4% of all coronary angiograms. Major complications are rare in today’s day and age. Despite low risk for major complications, every patient should be aware that there always exists the possibility of a complication. These may include:
- Damage to the coronary arteries (myocardial infarction/heart attack)
- Damage to the artery on route to the heart
- Arrhythmias prompting cardioversion (shock/defibrillation)
- Adverse reactions to medications used during the coronary angiogram such as contrast dye
- Damage to the heart itself causing tamponade (fluid around the heart causing hemodynamic disturbance)
- Bleeding requiring transfusions
- Damage to the kidney and reduction in kidney function
- Infection at the side of access or in the bloodstream (septicemia)
- Radiation damage to the skin or solid organs from x-rays
Most of the time coronary angiograms are outpatient procedures. It is usually performed that for an abnormal stress test or if you have symptoms that are truly convincing of obstructive coronary artery disease. Some of the time, coronary angiograms are performed emergency such as in a heart attack.
Coronary angiograms are performed in a catheterization laboratory. A catheterization laboratory appears like a mini surgical suite. You will most likely receive oral and/or written directions prior to an outpatient (scheduled angiogram). This includes knowing which medicines to hold prior to coronary angiogram, when you can last eat or drink, and what to expect the day of your procedure.
Your doctor will always and should always discuss the risks and the benefits of a coronary angiogram. This is very important, and should not be dismissed. You should ask your doctor his competency in performing such procedures and his complication rate.
In an outpatient basis, you will normally arrive to the catheterization holding room in the morning of the procedure. Certain medicines may be held by your doctor (such as diabetic medicines, blood pressure medicines, blood thinners). Typically, which medicines to take the night before or morning of your coronary angiogram should be explained to you during an outpatient visit. If you are unclear which medicines to take, ask your doctor. You will most likely have not eaten or drinking anything since midnight the night before. You will arrive to the catheterization laboratory by gurney by the Cath Lab staff or transporter. The doctor or the team will most likely visit you in the catheterization holding room and explain the procedure to you what to expect. Sometimes they will obtain consent for the procedure at that time, or may have received consent in the outpatient setting. You will arrive to the catheterization lab by gurney, transported to the catheterization table, and prepped.
Normally a “timeout” will be called prior to your procedure. This is a safety assurance to prevent errors. You may or may not receive sedation (most common combination of sedation is fentanyl and Versed). The doctor will anesthetize either your wrist or your groin region. This will most likely burn for about a minute. You’ll most likely feel pressure in some discomfort in the groin area or wrist depending on the access site that doctor has chosen. You will most likely not remember the procedure if you were sedated. . You should not feel significant pain during the procedure. After the procedure the doctor will most likely discuss your results with you and your family.
In an emergent basis (such as a large heart attack called STEMI or ST elevation myocardial infarction), you will most likely have the procedure briefly explained to reviewing the benefits and the risks associated with the procedure prior to urgently proceeding to catheterization. You will arrive to the catheterization laboratory in a hurried fashion, prepped, and perhaps receive sedation. The doctor will anesthetize the groin or the wrist depending on the access chosen. When receiving the anesthesia at the access site, it will most likely burn for a minute or so (feels like a wasp sting). You should not feel pain during the procedure. If you feel pain you should notify your doctor. The coronary artery that is blocked or causing problems will most undergo revascularization with a coronary stent (“fix the blockage”). After the procedure the doctor will discuss his findings and results with you and your family.
The Cath Lab team is usually composed of five people. A monitor (someone who is monitoring your heart rate, blood pressure, EKG, and records the minute to minute activity of the procedure), a circulator(someone who runs around gathering equipment needed for your procedure), a nurse (administers medications during coronary angiogram), scrub tech (assistant to the doctor during the procedure) and the doctor.
Before the coronary angiogram procedure begins the Cath Lab team will most likely have reviewed your allergies, medications, adverse reactions in the past, and concerns prior to the procedure. This is true for coronary angiograms and any medical procedure you undergo.
Please remember to go to the bathroom prior to getting prepped for your coronary angiogram. You may be asked to remove all jewelry and metal prior to the procedure.
During the procedure
You will most likely already have an IV in place. Electrodes will be placed across your chest to monitor your heart rhythm during the coronary angiogram. Your oxygenation will be monitored with a pulse oximeter (pulse ox). Your groin will most likely be shaved, washed, and disinfected prior to being covered with a blue sterile drape.
Although most of the time you will not remember the procedure since you will most likely receive sedation, sometimes patients remember portions of the procedure. Keep in mind that Versed is an amnestic anesthetic agent. Although you may be awake during the procedure, if you have received Versed, you will most likely not remember most of the coronary angiogram procedure.
You will lie on a thin table that moves during the procedure. It is best to keep your head down, hands at your side, and refrain from moving during the coronary angiogram. You will notice a big tube above your head. This is the x-ray image intensifier. It receives x-rays from the x-ray generator which is below you. You will be covered in sterile prep, which is most likely blue sheets, blankets, and cloths. The image intensifier (big tube above your head) will move around obtaining different angles of your coronary arteries.
A typical coronary angiogram takes approximately 10 minutes with an experienced cardiologist. However, preparation and recovery take up most of the time for the procedure. From the time you enter the room to finish of the procedure, a coronary angiogram would normally take approximately 45 minutes. Time of the coronary angiogram depends on the difficulty of the angiogram and the experience of the cardiologist and the Cath Lab staff. If a coronary artery has to be “fixed” (opened/revascularized), the entire procedure usually takes between 45 minutes and two hours.
After the procedure
After your coronary angiogram , the catheters are removed from the body. You may receive a manual pressure against the access site once the tube is removed from your groin or wrist. Most commonly, you will receive a closure device (if access is through the groin). This includes Starclose, Perclose, Mynx, or other closure device. If access was through your wrist, you will most likely receive compression with some sort of band like device that appears like a watch band. You may have to lay flat between 2 and 5 hours after your procedure to prevent you from bleeding. If your doctor chooses the radial artery access approach, you may sit up and even ambulate (able to walk) 10 minutes- 1 hour after the procedure.
You will be asked to lay flat for certain amount of time depending on what closure you received after your coronary angiogram. The advantage of having a coronary angiogram performed through your wrist is to be able to set up and even ambulate immediately post procedure. There’s also documented advantage to less bleeding risk through access from your wrist.
You will go to the recovery area and watched for acute bleeding or changes in vital signs (hemodynamic compromise) for a short period of time. Once you are stable you may be discharged home or kept overnight for observation depending on the doctor and his usual practice after coronary angiogram. It is becoming increasingly common to discharge patients, even after a stent has been placed, on the same day of the procedure (if coronary angiogram was in outpatient setting).
When to seek medical attention:
Although coronary angiograms have become a relatively safe procedure, sometimes complications occur. Once you are discharged, it is recommended you seek medical attention if any of these conditions occur:
- blood, excessive bruising, or swelling at the access site
- worsening pain or discomfort at the access site
- signs of infection such as redness, fever, drainage, tenderness, or malaise
- change in temperature or bluish discoloration of the leg or arm used for procedure
- feeling excessive fatigue or malaise
- chest pain, shortness of breath, dizziness, or any unusual symptom
Conditions that warrant prompt medical attention (Call 911 or have someone drive you to ER): very cold or very hot limb (leg or arm used as access in for coronary angiogram), excessive swelling/severe tenderness/pulsating mass at the access site where the catheters were inserted, fever (temperature >100.4 F), bleeding, excessive pain on the limb used for access during coronary angiogram.
Conditions that warrant a call to the doctor’s office: unusual pain at the access site used for coronary angiogram, mild swelling at the access site, excessive bruising at the access site, or any unusual symptom.
If you find yourself in a situation where you notice excessive swelling which occurs over a period of minutes to an hour, or you notice significant bleeding at the access site for the catheters were inserted, apply pressure with your hand and called the emergency medical system (DIAL 911). Do not release pressure on the access site until evaluated by emergency personnel.
Angiograms are very useful and provide your doctor with much information. It can show which arteries are obstructed (obstructive coronary artery disease or CAD) and which arteries have significant blockages that may require restoring blood flow with the stent or surgery. Coronary angiograms can also be used to evaluate previous coronary artery bypass grafting (CABG), reveal which bypass grafts have failed, and to evaluate previously stented arteries.