Elsevier

Heart, Lung and Circulation

Volume 29, Issue 2, February 2020, Pages 169-177
Heart, Lung and Circulation

Review
Sedation and Analgesia for Cardiac Catheterisation and Coronary Intervention

https://doi.org/10.1016/j.hlc.2019.08.015Get rights and content

Background

While cardiac catheterisation is typically well tolerated, discomfort and anxiety are commonplace. Sedation using anxiolytic and analgesic medications has the potential to ameliorate such symptoms, however, is variably employed, with lack of standardised regimens and limited evidence.

Methods

We performed a review of the role of sedation for cardiac catheterisation, including current practices and summarising available evidence relevant to diagnostic and interventional coronary procedures in the cardiac catheterisation laboratory.

Results

Use of sedation and the medication regimens employed are highly variable. Available relevant studies are limited in number and mostly small. Sedation appears to modestly reduce anxiety and pain in most studies. The incidence of radial spasm and the consequent need to alter access site is reduced with procedural sedation. The majority of existing evidence applies to benzodiazepines and opioid use, which appear acceptably efficacious and safe when used with appropriate training and staffing; noting opioid medications reduce the absorption of loading doses of oral anti-platelet drugs.

Conclusions

In conclusion, benzodiazepines and opioids result a modest reduction in pain, improved patient tolerability and reduced risk of radial artery spasm. The decision on whether to use sedation, and which agent(s) and dose, should be individualised based on patient factors, including need for oral antiplatelet therapy administration. Appropriate staffing and monitoring is essential.

Section snippets

Background

Cardiac catheterisation and percutaneous coronary interventions (PCI) are typically well tolerated; however, significant pain and anxiety may occur during and following the procedure, potentially influencing outcomes. The American College of Cardiology Foundation/Society for Cardiovascular Angiography and Interventions Expert Consensus Document on Cardiac Catheterization Laboratory Standards Update [1] states “Appropriate sedation is imperative and ensures patient comfort”, however, specific

Methods

We performed a review of the literature. Databases searched (1 January 1996 to 1 June 2017) included Medline, EMBASE and the Cochrane Database of Systematic Reviews. Reference lists from relevant articles were examined and any further pertinent articles obtained. The Clinicaltrials.gov website was searched for relevant trials. Guidelines were obtained and their reference lists examined. Search strategies are available in the supplementary material.

In this review, the term sedation is used to

Existing Guidelines for Procedural Sedation

There are limited studies available to guide sedation for cardiac catheterisation. Society guidelines including the American College of Cardiology Foundation/Society for Cardiovascular Angiography and Interventions (ACCF/SCAI) Expert Consensus Document on Cardiac Catheterization Laboratory Standards Update [1], and the Cardiac Society of Australia and New Zealand Position Statement on Sedation for Cardiovascular Procedures [4] provide recommendations for standards surrounding the administration

Current Approaches to Procedural Sedation

Clinical practice appears to be highly variable in the use of sedation [5]. Bertrand et al. [2], in an international survey of transradial practices, reported that, before the patient enters the catheterisation suite, 42% of respondents prescribe anxiolytic agents, with smaller proportions giving antihistamines and topical lidocaine; however 45% prescribe no therapy. Lavi et al. [3] found that sedation is routinely prescribed by 92% of cardiologists from North America, compared to 38% of

Patient Comfort and Anxiety

Several studies addressing the role of periprocedural sedation for patient comfort have yielded conflicting results. Woodhead et al. [7] randomised 760 patients 1:1 to diazepam 5–10 mg, 30–60 minutes prior to procedures, or to no premedication. There was no difference in the number of patients experiencing periprocedural anxiety (36% vs 37%), however those premedicated with diazepam were significantly less likely to report periprocedural pain (32% vs 53%, p = 0.0114). Beddoes et al. [8]

Interactions Between Sedative Agents and Cardiac Procedural Drugs

The recognition of potentially clinical relevant interactions between the absorption of differing anti-platelet agents following administration of opioids may impact on the decision to utilise procedural sedation, particularly in the acute setting when predictable, rapid P2Y12 inhibition is essential.

Multiple studies have demonstrated delayed and/or reduced activity of loading doses of antiplatelet agents (ticagrelor, prasugrel, and clopidogrel) when morphine has been administered in the

Practical Considerations

If procedural sedation is planned, there are a number of factors that should be addressed including patient selection, choice of agent, monitoring and staffing. An understanding of the spectrum of depth of sedation (Table 1) is important when utilising sedative medications.

Discussion

Sedation practices vary widely and there is limited evidence regarding the role of sedation for cardiac catheterisation. The available studies have examined diverse drug regimens with heterogeneity in outcome measures, limiting explicit recommendations. Experience and evidence from other settings, such as endoscopy, are not directly applicable to cardiac catheterisation due to inherent differences in patient population, nature of stimuli, required level of sedation, and the desire to avoid

Conclusions

There is limited evidence to guide the optimal use of sedation for cardiac catheterisation and coronary intervention. Benzodiazepines and opioids likely result in reduced pain and improved patient tolerability and reduced risk of radial artery spasm. The decision on whether to use sedation, and which agent and dose, should be individualised based on patient factors. The antiplatelet drug status of the patient should be taken into consideration when opioids are contemplated as opioids reduce

Sources of Funding

No funding was received for this work.

Disclosures

The authors have no relevant disclosures.

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    © 2019 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.