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Cardiology
Patient Selection, Preparation, Risks, and Informed Consent
Built from Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
What’s inside
5 sections · 98 slides
Overview
- Scope of this topic
- Rationale for a rigorous preprocedural approach
Patient selection
- Determinants of candidacy for catheter-based procedures
- Sequence of preprocedural evaluation
- Indications in coronary artery disease
- Indications in valvular and other cardiovascular disease
- Guidelines and evolving therapeutic indications
- Shift toward transcatheter aortic valve replacement
- Categories of procedural contraindication
- Components of assessment before an invasive procedure
- Cardiac catheterization laboratory
- Anatomic assessment in structural heart procedures
- Anatomic assessment before coronary procedures
- Selective coronary angiogram
- Coronary computed tomography angiography
- Three-dimensional cardiac computed tomography reconstruction
- Vascular access assessment
- Planning secondary and large-bore access
- Patients warranting dedicated preprocedural vascular imaging
- Arterial access sheath and guidewire
- Age and functional status in patient selection
- Quantitative risk scores used before catheterization
- Life expectancy and comorbidity review
- Illness acuity and procedural timing
- What the qualitative assessment table decides
- Key Points in Qualitative Preprocedural Assessment ⏎
Preprocedural preparation
- Elements of preprocedural patient preparation
- Aspirin before coronary angiography
- Timing of P2Y12 inhibitor administration
- Antiplatelet therapy in urgent and emergent presentations
- Statin administration before percutaneous coronary intervention
- Balloon angioplasty and stent deployment in a coronary artery
- Principles of periprocedural anticoagulant management
- Warfarin and direct oral anticoagulants before arterial access
- Antithrombotic regimen after PCI in the anticoagulated patient
- Insulin and metformin around the procedure
- Oral hypoglycaemic agents and SGLT2 inhibitors
- GLP-1 receptor agonists before a procedure
- Renin-angiotensin system blockers and diuretics
- Institutional medication policies
- How to read the medication management table
- Managing medications prior to catheterization procedures
- Managing medications prior to catheterization procedures (continued)
- Managing medications prior to catheterization procedures (continued)
- Nil per os status before catheterization
- Allergy assessment before catheterization
- Latex allergy in the catheterization laboratory
- Balloon-tipped pulmonary artery catheter
- Pulmonary artery catheter ports and course
- Contrast media allergy and premedication
- Aspirin allergy before percutaneous coronary intervention
- Heparin allergy and heparin-induced thrombocytopenia
- Alternatives to allergenic agents in the catheterization lab
- Local anaesthetic allergy
- Allergy to sedative and analgesic agents
- Addressing allergies in the cardiac catheterization lab
Procedural risks
- Framing procedural risk
- Mortality of diagnostic left heart catheterization
- Factors increasing periprocedural mortality
- Periprocedural myocardial infarction
- Contributors to the fall in periprocedural infarction
- Coronary stent expanded within a diseased artery
- Stroke risk with catheterization and intervention
- Mechanism of periprocedural ischaemic stroke
- Vascular complications by access site
- Radial artery spasm
- Other transradial complications
- Transradial haemostasis after sheath removal
- Bleeding risk factors with femoral arterial access
- Contrast-associated nephropathy
- Mitigation of contrast-associated kidney injury
- Embolic renal injury and infection
- Contemporary rates of major complications of diagnostic left heart catheterization
Informed consent
- Legal basis of informed consent
- Best practices for a patient-centred consent discussion
- Consent as an opportunity to build trust
- Patient recall of disclosed risks
- Consent in the emergency setting
- Conclusion
- Numbers to carry from this topic
- References
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- Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
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