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Cardiac Catherization

OVERVIEW

A cardiac catheterization is a common, nonsurgical procedure that allows physicians to determine if there are any narrowings (blockages) in the arteries that provide blood supply to the muscle of the heart. It also can show the physician the heart size and pumping ability, the inside chamber size, and how well the valves open and close. The procedure is done by inserting a small flexible tube (catheter) into a blood vessel (usually via the groin) and gently advancing it to the heart. Blood pressure measurements are taken and moving X-ray pictures (angiograms) are recorded using digital imaging.

Our Catheterization and Interventional labs are staffed by specially trained physicians, nurses and technologists to provide high quality care and effective treatment for patients with heart and vascular diseases. The Cardiovascular Catheterization Laboratories at Stony Brook Medicine perform approximately 4,000 diagnostic procedures and more than 2,200 interventions annually. As a primary investigational site for new treatment modalities, we continue to make great strides in improving long-term benefits while providing the best possible care for our patients.

As a patient, you are a part of our team. We think it is important for you to know what to expect before, during and after a cardiac catheterization. We believe that when you know what to expect you will not worry as much, and you will recover better.

PRE-ADMISSION TESTING

Once your physician determines that you need a cardiac catheterization, various tests will help properly assess your condition prior to the procedure. You may have already done tests before your referral; however, Stony Brook Heart Institute staff may request additional testing.

The following are necessary prior to scheduling a catheterization:

  • A history and physical examination by a cardiologist or an accredited Nurse Practitioner
  • An electrocardiogram (EKG)
  • Blood tests

Other tests may be requested:

  • Exercise tolerance test (treadmill test)
  • Echocardiogram (an ultrasound study)
  • Gated blood pool scan (nuclear scanning of your heart)
  • Chest X-ray

PREPARING FOR YOUR HEART PROCEDURE

Preparing for Your Heart Procedure at Home
lIf you are scheduled for admission on the day of your procedure, follow these specific preparation instructions:

  1. Do not eat food or drink (except a few sips of water with medication) after midnight.
  2. Continue to take medications on your prescribed schedule. Medications such as Coumadin, diuretics, insulin and oral diabetic medication will require individual review by your physician.
  3. Discuss medications, allergies, and any other issues with your doctor prior to the procedure
  4. The afternoon prior to your procedure, a nurse from the Cath Lab will contact you to provide additional instructions and let you know when to arrive at the Cath Lab. Please use this opportunity to address any questions or concerns about your procedure.
  5. For your same-day admission, please arrive in the Cath Lab at your designated time. A family member or friend may accompany you. For your convenience, there is a comfortable reception area with cafeteria services and public phones nearby.
  6. It is not necessary to bring anything with you except personal toiletries and medications you may need. Please do not bring any valuables or jewelry. Wear comfortable clothing and walking shoes. Please bring a book or other diversion to help pass the time in case of delays.
  7. When you arrive at the Heart Institute, located on the 5th floor of the main building, a receptionist will greet you and notify the team that you have arrived. As your procedure time nears, a nurse will ask you to change into hospital attire. You are then brought into the pre-procedure holding area.

Preparing for Your Heart Procedure in the Hospital
For patients in the hospital, a Cath Lab physician will visit you the evening before your procedure. At this time, you have an opportunity to discuss the catheterization procedure, ask any questions and sign a consent form.

Adjustments may be made to your prescribed medication routine, and an IV will be inserted. You will not be able to eat or drink (except water with medications) after midnight. Your nurse will ensure that you are properly prepared.

WHAT TO EXPECT

In the Pre-Procedure Holding Area
During your wait in the pre-procedure area, a nurse will review your medical record and discuss any questions or concerns you may have. The nurse will check your vital signs, assess the circulation to your legs and insert an IV.

You will meet one of the physicians scheduled to perform your catheterization. The physician will explain the procedure in greater detail and outline the potential risks. If you have not already done so, you will sign a consent form indicating your willingness to have a catheterization performed.

The nurse will administer pre-catheterization medications, consisting of a mild sedative to relax you.

During the Cardiac Catheterization Procedure
Once you are in the procedure room, you will be moved to a flat, moveable examination table. Cameras are located above, below and to the sides of the table. There will be many monitors visible around the room. The nurse and technologist, who will be with you and assist the physicians during your catheterization, will begin the pre-catheterization preparation.

Electrodes will be attached to your chest to monitor your heart rate and rhythm during the procedure. The selected area for insertion of the catheters will be shaved and washed with an antiseptic to ensure that the catheter entry site is clean and sterile. You will be draped with a sterile sheet to provide the most sterile environment for catheter insertion. The most common entry site is the upper area of your right groin, but occasionally the middle of the arm is preferable.

Sedation
You will be mildly sedated throughout the procedure. It will be necessary for us to communicate with you, and we need to know if you are experiencing any discomfort. If you feel anxious, you may request additional sedation.

A local anesthetic is injected to numb the skin at the insertion point, and you may experience a brief burning or stinging sensation. An introducer sheath (small tube) is placed in the groin artery and in the vein. The sheath acts as the entry tube for the various catheters required during the procedure. Some patients feel pressure or mild discomfort when the sheath is being inserted.

Physicians need to obtain a variety of information relevant to each patient's clinical situation. Therefore, the sequence and type of measurements collected may vary from patient to patient.

The Procedure: Recording Pressures and Pictures
From this point on, the lights will be dimmed periodically for viewing purposes. Typically, pressures are recorded in the various chambers and vessels of your heart. It is important not to talk as pressures are recorded because measures should reflect a normal resting pressure. You should not experience any discomfort; however, be sure to tell the staff if you feel uncomfortable.

Physicians will take pictures of your arteries and the main pumping chamber. To accomplish this, the doctor will manually inject dye through a catheter into the artery that supplies blood to the heart muscle. You may feel pressure in your in chest when the dye is injected, and it is important for you to tell us if this happens. X-ray cameras will move around your chest, and the table will move so the dye can be followed as it travels through the vessels. Many pictures will be taken from different angles to thoroughly understand the blood flow through your arteries.

A catheter will be placed into the left pumping chamber of your heart. This time a machine will inject dye. Moving pictures will evaluate the left ventricle and main pumping chamber functions. This causes a momentary hot and flushed feeling throughout your body. These feelings should pass quickly.

Discussing the Results with Your Physician
After all measures are taken, your physician will discuss the findings with you and present options for further treatment. Your options may include:

  • No treatment
  • A change in medications
  • Another type of catheterization called an interventional procedure
  • Cardiac surgery

If an intervention is recommended, it is often done while you are still in the procedure room. The type of interventional procedures performed is based on severity, location and degree of blockage.

After the Procedure
If no other tests or treatment are required, the cardiac staff will prepare to bring you to the post-procedure area for recovery. A nurse may administer additional medication, drapes will be removed and monitoring equipment will be disconnected. You will need to keep your leg straight, particularly as you are moving from the table to a stretcher.

In the recovery area, your sheaths will be taken out. This may cause pressure or discomfort at the entry site. Immediately after the sheath is removed, the staff will apply firm and direct pressure by hand or with a clamp device. Pressure is maintained for approximately 20 to 30 minutes to help stop bleeding and to allow the puncture site to heal. A nurse will continue to monitor your blood pressure, heart rate, the entry site, and your circulation. Once the staff is sure that the entry site is stable, an adhesive strip will be applied.

The four to six hours following your catheterization are very important, and we ask that you carefully follow these instructions about your care. A nurse will frequently check your vital signs and make sure your entry site is healing properly.

Please tell the staff immediately if you experience the following:

  • Chest, neck, jaw, or arm pain, or any pain similar to your heart pain
  • Shortness of breath
  • Weakness or dizziness
  • Pain at the entry site
  • Numbness, tingling or any discomfort below the entry site
  • A warm or wet sensation around the entry site area
  • Any other discomfort

Bed rest is essential to ensure that the puncture site heals. You will need to lie flat, and you may only raise your head slightly (30 degrees). You should not turn from side to side. You may bend your foot or wiggle your toes, but do not bend your knee. If you have to cough or sneeze, apply firm, direct pressure over the adhesive strip on your groin.

You will need to drink extra fluid to help your kidneys eliminate the X-ray dye. Since you will not be able to get out of bed, a nurse will assist you in the use of a urinal or bedpan.

Back discomfort may occur. Please let us know if you are concerned about your back. We will try to alleviate your discomfort.

Following your resting period, a nurse will help you get out of bed. This should be done slowly and carefully. We recommend that your initial activity be limited to short trips (i.e. possibly to a nearby bathroom). The following day you may resume light activity.

If you are going home the evening of your procedure, you will be given additional written instructions before you are discharged.

Please be prepared for the following:

  • Plan to stay in the hospital for six to eight hours after your procedure is finished.
  • Have an escort or family member pick you up and drive you home from the hospital.
  • You cannot spend the night following your catheterization home alone.
  • Please plan to have a companion with you.
  • Limit your activity to your trip home.
  • Resume light activity (around home) the next day.

Before you leave, discuss these important points with your physician:

  • The findings of your catheterization
  • Your activity level
  • Your medications
  • Who to contact in the case of an emergency
  • Any other details specific to your care

UNDERSTANDING HEART ATTACK

Heart Attack
One of the major causes of death in the U.S., a heart attack occurs when blood flow to a section of heart muscle becomes blocked, preventing it from receiving the oxygen it needs. If not treated relatively quickly, the muscle will become damaged and possibly die.

In doubt? Call 911
A heart attack (also known as myocardial infarction) is a serious and often fatal condition. If you think you or someone with you is experiencing a heart attack, you should seek medical attention immediately by dialing 911. If the blood flow can be restored in time, damage to the heart can be limited or prevented.

Signs and Symptoms
The signs and symptoms of heart attacks can vary from person to person. For example, symptoms in women and people with diabetes may tend to be less pronounced. Some warning signs and symptoms to be aware of are:

  • Pressure, fullness, or a squeezing discomfort in the center of your chest that may radiate to the shoulders, arms, jaw, and back, and lasts for more than a few minutes. (Angina, which has similar symptoms, goes away with rest.)
  • Shortness of breath
  • Sweating
  • Lightheadedness, weakness, possibly even fainting
  • Nausea and vomiting
  • Impending sense of doom

Heart Attack - Risk Factors

The following factors can contribute to the likelihood of having a heart attack:

  • High Blood Pressure. Over time, prolonged high blood pressure (> 140/90) can damage arteries that feed your heart its blood supply, contributing to atherosclerosis (hardening of the arteries). The risk of high blood pressure increases with age and can also be an inherited problem. Eliminating high sodium foods and obesity will aid in keeping blood pressure down.
  • High Cholesterol Levels. Cholesterol accounts for a large part of deposits that can narrow arteries throughout your body, especially the coronary arteries that feed the heart. There is good cholesterol (HDL) and there is bad cholesterol (LDL). The LDL cholesterol is most likely the cause of narrowing arteries contributing to heart disease and is found in foods high in saturated fat. HDL cholesterol helps your body clean up excess cholesterol and lowers your risk for heart disease.
  • Cigarette Smoke. Smoking and long-term exposure to smoke causes damage to the interior walls of the arteries, allowing deposits of cholesterol to build up and hamper blood flow. Smoking also increases the formation of blood clots that can cause heart disease.
  • Obesity. Obesity raises the risk of heart disease because it is often associated with inactivity, high blood pressure, high cholesterol levels, and diabetes.
  • Diabetes. Diabetes raises the risk of heart disease by speeding atherosclerosis and negatively affecting cholesterol levels.
  • Stress. Too much stress can increase your risk for heart disease by raising blood pressure. High stress can also lead to poor self-care - for example eating high-fat foods and not exercising properly.
  • Alcohol. Excessive drinking can raise your risk for heart disease by raising your blood pressure and raising certain types of harmful cholesterol levels. Alcohol in moderation, however, can help raise HDL cholesterol levels and help prevent heart disease.
  • Family History of Heart Disease. Family genetics may predispose you to increased cholesterol levels and high blood pressure. You are at an increased risk if your siblings, parents or grandparents have had early heart attacks. Unfortunately, we are unable to change our genetic makeup. However, following a healthy lifestyle will help decrease your chances of heart disease.

Heart Attack - Diagnosis and Treatment

If you have had a heart attack, the following tests may be performed to further investigate possible damage:

  • Electrocardiogram (ECG). This test to show the electrical conduction of the heart will be the first one to be done to diagnose a heart attack. During a heart attack, the heart muscle is injured and it won't conduct electricity normally. This will be shown on the ECG. Initial blood tests may be done to determine if there has been damage to your heart. If damage to the heart muscle has occurred, enzymes slowly leak into your blood flow. These enzymes are measured in blood tests called troponin and CK.
  • Cardiac Nuclear Scan. This test helps identify blood-flow problems with the heart. By injecting radioactive material through an IV site, physicians will be able to identify areas of the heart that are not getting appropriate blood supply.
  • Echocardiogram. This test can help identify whether an area of your heart has been damaged by a heart attack. Using sound wave technology, it can provide images of your heart and can detect poor heart wall motion, an indicator of heart damage. It can also help us see the 4 valves of the heart and their function.
  • Cardiac Catheterization. This test can help determine whether your coronary arteries are narrowed or blocked. This is done by placing a small tube (catheter) into an artery, usually in the groin, which is fed to the arteries of the heart. After advancing this catheter to the heart, we are able to see the arteries that supply blood to the muscle of the heart (coronaries) by injecting a liquid dye and with the help of X-Rays, thereby revealing areas of blockages (also known as angiography). Additionally, if a blockage is discovered, the area can be treated while the catheter is in place in a procedure called angioplasty.
  • Percutaneous Cardiac Intervention (PCI). Similar to the cardiac catheterization, this test can actually treat blockage by using balloon angioplasty and/ or by placing a stent. Balloon angioplasty is a catheter with a balloon tip that is fed through the arteries to the blockage. The balloon is opened and pushes plaque back against the arterial wall, which allows for improved blood flow. Coronary stenting often accompanies angioplasty. Stents are small wire mesh devices used as scaffolding to support and open the arterial wall, thereby reducing the chance the artery will re-close. PCI usually takes 1-2 hours to complete and is done with local anesthesia. Blood thinners may be used through an IV to prevent clotting. A medication called clopidogrel (Plavix) along with aspirin is usually prescribed for three months (depending on physician practice) to prevent blood clot formation within the affected vessel.
  • Coronary Artery Bypass Surgery. Of those people who have heart disease, approximately 10% will undergo coronary artery bypass graft surgery (CABG). Those with severe narrowing or blockages, especially involving multiple arteries, may be considered for bypass surgery. This is an operation performed by a surgeon and done under general anesthesia. The surgeon takes a healthy vessel from the leg, chest or arm and creates a bypass around the blockage, restoring blood flow to the heart muscle. Typically, one to five bypasses can be done, depending upon how many coronary arteries are blocked. A CABG procedure usually requires about a five-day stay in the hospital and up to three months to fully recover from the surgery.

Prevention, Medications, and Lifestyle

Prevention.
It's never too late to take steps to prevent a heart attack, even if you have had one in the past. Medications, lifestyle changes, and coping skills are all ways to keep your heart healthy. Here are some suggestions:

Medications
Your doctor may prescribe drug therapy if you have had a heart attack or are at high risk for one. Medications help the heart pump and function more effectively. Some of these medications include:

  • Blood thinning medications. A daily dose of aspirin can help prevent the blood from becoming "sticky." Your doctor might prescribe other bloodthinning medications, such as clopidogrel (Plavix), especially if you had a stent deployed inside one of your arteries.
  • Beta blockers. These medications decrease the workload of the heart by lowering heart rate and blood pressure. One type of beta-blocker your doctor may prescribe is called metoprolol (Lopressor, Toprol).
  • Angiotensin-converting enzyme (ACE) inhibitors. These medications help blood flow from your heart more easily. They are prescribed if a heart attack has occurred that has reduced the heart's pumping function. An example of an ACE inhibitor is lisinopril (Zestril).
  • Cholesterol-lowering agents. There are a variety of cholesterol-lowering medications, such as statins (including Pravechol) and niacin. A majority of people who have had a heart attack take cholesterol-lowering agents, which will reduce the risk of a second heart attack.
  • Calcium channel blockers. These medications (including Diltiazem and Cardizem) help relax the blood vessels and can also slow the heart rate.

Lifestyle Changes
The way you live affects your heart health. By establishing and following a healthy lifestyle, you can prevent further and future damage to your heart. Here are some key lifestyle tips to help you live heart smart:

  • Have regular medical check-ups. By seeing your doctor regularly, previously undiagnosed problems can be treated promptly and thereby prevent heart damage. Your doctor can also perform tests that assess heart problems or cardiovascular disease.
  • Have your blood pressure and cholesterol checked regularly. Keeping your blood pressure and cholesterol in check will prevent heart damage from occurring.
  • Stop smoking. It's the most important thing you can do to prevent future heart attacks. Continuing to smoke doubles your risk of a second heart attack or heart-related death. If you cannot stop smoking on your own, ask your doctor to prescribe a treatment to help you kick the habit.
  • Maintain a healthy lifestyle. Exercise regularly. Eat a healthy diet. Maintain a healthy weight. Limit fatty, high sodium meals. All these changes will reduce your chances of heart problems. And they'll make you feel much better, too!
  • Manage the stress in your life. This will help reduce the stress on your heart. Avoid unhealthy ways of dealing with stress. Rethink your workaholic tendencies and never abuse alcohol to deal with stress.

Coping Skills
It is quite normal to be emotional after having a heart attack or a heart-related crisis. Feelings of fear, anger, and depression are very common-not only for the person who had the event, but also for loved ones. It is important to be able to talk about your feelings and discuss your heart attack and recovery. This is all a part of the healing process and should resolve in time. If you notice these feelings persisting and you are having difficulties coping, talk with your doctor. He or she may be able to refer you to a support group or counselor.

Having a heart attack doesn't mean that life as you know it is over. By adjusting your lifestyle and making healthy changes, you can live a healthy, happy life.