Indications for cath.

[marly]

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I was wondering if they have strict guidelines for cath in a patient who has some ekg changes.

This is a 58 yo female with DM, and HTN, was admitted for worsening SOB/ ankle edema treated for new onset CHF. Cardiac enzymes normal, however she has some new T wave inversions, Echo EF 44 %, mile TR/ MR, no wall motion abnormalities.
1/ should she have cath or stress test is adequate ??

2/ Can she receive beta blockers while in hospital ?

thank you.

 

[tibor75]

I was wondering if they have strict guidelines for cath in a patient who has some ekg changes.

This is a 58 yo female with DM, and HTN, was admitted for worsening SOB/ ankle edema treated for new onset CHF. Cardiac enzymes normal, however she has some new T wave inversions, Echo EF 44 %, mile TR/ MR, no wall motion abnormalities.
1/ should she have cath or stress test is adequate ??

2/ Can she receive beta blockers while in hospital ?

thank you.

Every patient admitted with new onset CHF without an identifable reason (i.e. new AF, severe HTN, AS, pheo, etc etc) has a definite indication for cath. Would not stress. If they had CHF as a result of new AF, they might still have CAD, and you probably would cath, but could do stress test first provided you got them into sinus rhythm. Of course, if they had AS, you would cath them b/f operating.

Would definitely begin beta blockade. Her EF is good enough that you don't have to worry about the loss of ionotropy. Not harm in waiting though until you get some fluid off of her first


Make sure somebody didn't start her on Avandia a few weeks ago first. 😀

 

[marly]

Patients have cath assuming they have high probability of having stenosis significant enough to have PTCA or CABG.

In AS or any other valvular heart disease, I don't understand what additional information you get that you don't get from a 2 D echo.

Thanks.

 

[cowbell]

I agree with tibor75 about getting the cath. This lady is presenting with known risk factors and symptoms of CHF with mildly impaired LVSF. The reason for cath is to identify compelling multivessel CAD or its equivalent. Given that her cardiac biomarkers were negative, it would make the most sense to diurese her first (so she can comfortably lay flat for the cath), beta-block her, then cath her. There is no great hurry unless her symptoms, ECG, or biomarkers show signs of instability. The question of compelling CAD is sometimes missed by non-invasive imaging due to "balanced ischemia". This is a classic Bayesian clinical scenario. Given her presentation and risk factors, she has an intermediate to high pre-test probability of CAD, so best to go with the diagnostic test that gives an acceptable post-test probability given a negative or positive test, i.e. cath.

 

[tibor75]

In AS or any other valvular heart disease, I don't understand what additional information you get that you don't get from a 2 D echo.

Thanks.

You look at the coronaries in AS before underoing valve surgery as you want to make sure you don't need a CABG at the same time.

 

[cowbell]

In AS or any other valvular heart disease, I don't understand what additional information you get that you don't get from a 2 D echo.

Thanks.

I'm not too sure about the crux of your question. If it is asking why we perform coronary angiograms in patients about to under go aortic valve replacements, I wholeheartedly agree with tibor75. If somebody has co-existing CAD, you can treat it at the same time while on bypass.

If you're asking about why we perform diagnostic hemodynamic catheterization in someone carrying an echocardiographic diagnosis of aortic stenosis, then the answer is a bit more complicated. An ECHO evaluation of the severity of AS really depends on a number of assumptions. The Doppler calculation based upon the continuity equation requires the CW probe to be parallel with the aortic valve flow, which cannot always be done perfectly depending upon the body habitus. Inaccurate doppler measurements (and often inaccurate LVOT measurements) contribute to overestimation of aortic valve areas (and underestimation of severity). Good echocardiographers use a non-imaging probe, but expertise in this nowadays is quite an art. So, the long-winded answer is that when the ECHO gives information that is discordant with the clinical scenario, then you can move on to a hemodynamic cath if the added information would affect/change clinical management (calculating aortic valve area by Gorlin or Hakke equations).

In general, cath with hemodynamic measurements (and contrast injection) can be very useful for diagnosing numerous valvular diseases where clinical impressions do not entirely agree with other objective studies.

 

[marly]

when you do cath how often do you do left femoral artery cath ?? 'cos the right side cath will measure right chambers/ and the left the other side, right ?

do you ever go through the femoral vein ??

finally Pul. artery pressure when measured by Echo( for eg as 75 mm Hg on this patient) how accurate is this ?

 

[cowbell]

when you do cath how often do you do left femoral artery cath ?? 'cos the right side cath will measure right chambers/ and the left the other side, right ?

do you ever go through the femoral vein ??

finally Pul. artery pressure when measured by Echo( for eg as 75 mm Hg on this patient) how accurate is this ?

Understanding of the physiology for these questions is more fitting for a cardiology fellow, and judging by the nature of your questions, I would guess you are a medical student. In any case, I'll walk you through some of the basics.

To do an invasive calculation of aortic valve area, you need to perform both femoral venous and arterial access. The venous catherization is necessary to introduce a pulmonary artery (PA) catheter. This is necessary to obtain the measurements required for calculating the cardiac output (assuming there is no significant shunting). The arterial catheterization is required to measure the pressure difference between the left ventricle and aorta. So, information from both left and right sided caths are used to calculate aortic valve (or mitral for that matter) area. BTW, how did we get to talkinga bout aortic valve disease when this patient doesn't appear to have the problem?

As for a right heart cath, it can be very informative for left-sided pressures. It is routine practice to take a pulmonary capillary wedge pressure (PCWP) to obtain LEFT atrial pressures. I'll let you read about this one. Look up PCWP.

Non-invasive estimation of chamber pressure by ECHO depends upon doppler measurements of regurgitant flow velocity between two chambers. This means that you need a good doppler "envelope" of regurgitant flow to calculate the difference of pressure between two chambers. According to your first post, this patient has "mild" TR, which is usually sufficeint for this type of measurement. We use a simplified Bernoulli's equation to calculate the PA pressure. PA pressure = (4 x velocity^2) + right atrial (RA) pressure. In ECHO, we assume the RA pressure by the dimensions and inspiratory collapse of the IVC in subcostal views. The greatest variability here is the assumed RA pressure. When in doubt, the best thing to do is look at the JVP at the time of the ECHO exam and you can assess a very accurate RA pressure. Overall, the ECHO is very good for instantaeous PA pressures when sufficient TR is present for good measurements. I have found that ECHO correlates very well with my invasive measurements. Granted, like any ultrasound-based technology, the quality of the study depends very much on the expertise of the sonographer.

 

[cowbell]

If this lady is your patient, please listen carefully.

The information you presented thus far is a semi-elderly lady with diabetes and hypertension presenting with symptoms of heart failure, ECG changes (new TW abnormalities), and mild-moderately impaired LVSF with severe pulmonary hypertension.

Your operating diagnosis, despite no regional wall motion abnormalities on the ECHO, should be compelling CAD with an eye toward CABG for revascularization! This lady is in fact very sick, and you want to maximize her chance of getting out of the hospital alive.

Her severe pulmonary hypertension, given her risk factors and LV impairment, is likely to be attributable to elevated LV diastolic pressures (rather than primary PAH), and is also likely to come down with normalization of LVEDP. Remember that many patients come out of CABG in the same overall state that they go into it. Go in sick, and you come out sick with a higher mortality. Go in well-compensated, come out well-compensated with a higher chance of being extubated and flying solo. Get it?

So, I highly advise not rushing to cath (with the extra volume and contrast load) unless the patient shows signs of instability. Start aspirin and statins, do not give plavix, diurese her well (and hopefully her PA pressures will come down), beta-block her, and don't cath her until she is well-compensated and ready for CABG. If you cath her now, she could decompensate even more, and also, you might end up rushing towards surgery decreasing her chance at a nice outcome.

 

[marly]

It took 2 days for a decision to be made... and she did go for a cath.

She was found to have significant CAD affecting 3 major vessels including complete occlusion of RCA. The lady is waiting for a CABG now.

 

[cowbell]

It took 2 days for a decision to be made... and she did go for a cath.

She was found to have significant CAD affecting 3 major vessels including complete occlusion of RCA. The lady is waiting for a CABG now.

It took TWO days to make a decision??? It should take less than 2 MINUTES to make the ONLY correct decision for this patient. My God...

 

[tivark]

contraindications for cath at the cleveland clinic, ohio:

Relative: no groin
Definite: no artery

 

[Gastrapathy]

It took TWO days to make a decision??? It should take less than 2 MINUTES to make the ONLY correct decision for this patient. My God...

Come on now, essentially accusing someone of malpractice based on a case presentation from a ?medstud? who doesn't understand the basics is pretty unfair. More likely, the staff knew the plan, and the "decision" was made to cath her after treating her acutely decompensated HF. I bet they were just waiting until it was safe to take her to the lab since she wasn't acutely ischemic.

 

[cowbell]

Come on now, essentially accusing someone of malpractice based on a case presentation from a ?medstud? who doesn't understand the basics is pretty unfair. More likely, the staff knew the plan, and the "decision" was made to cath her after treating her acutely decompensated HF. I bet they were just waiting until it was safe to take her to the lab since she wasn't acutely ischemic.

Stop being so melodramatic. Any member of the team, even a med student, should be able to detect whether there is a decisive plan for management or whether there is some continued discussion. I have not made ANY assertions that the OP is incapable of listening or unable to pick up on the team's strategy for management as YOU have been implying. I have given the OP the benefit of the doubt in this regard, where you have not.

And who is accusing the OP of "malpractice"? Only a cardiologist can make the decision to take someone to cath, and I think we would all agree that Marly is not (yet) a cardiologist. The information Marly presented thus far should be sufficient for a decent cardiologist to arrive at a reasonable plan for management, and my criticism was leveled at the staff (likely a general medicine attending trying to decide whether to consult cardiology for cath). If Marly did not understand the plan for management, then it is an even worse reflection on the staff for not taking advantage a prime bread and butter case for teaching. The OP clearly wants to learn some cardiology, and I am more than happy to help. Are YOU helping with your Monday morning quaterbacking?