AFTER THE PROCEDURE

Assess vital signs, catheterization site for bleeding or hematoma, peripheral pulses, and neurovascular status every 15 minutes for first hour, every 30 minutes for the next hour, then hourly for 4 hours or until discharge. The data provide vital information about the clients status and potential complications such as bleeding,hematoma, or thrombus formation. Maintain bed rest as ordered, usually for 6 hours if the femoral artery is used, or 2 to 3 hours if the brachial site is used. The head of the bed may be raised to 30 degrees. Bed rest reduces movement of and pressure in the affected artery, reducing the risk of bleeding or hematoma. Keep a pressure dressing, sandbag, or ice pack in place over the arterial access site. Check frequently for bleeding (if the access site is in the groin, check for bleeding under the buttocks). Arteries are high-pressure systems.The risk for significant bleeding after an invasive procedure is high. Instruct to avoid flexing or hyperextending the affected extremity for 12 to 24 hours. Minimizing movement of the affected joint allows the artery to effectively seal and promotes blood flow, reducing the risk of bleeding, hematoma, or thrombus formation. Unless contraindicated, encourage liberal fluid intake. An increased fluid intake promotes excretion of the contrast medium, reducing the risk of toxicity (particularly to the kidneys). Promptly report diminished peripheral pulses, formation of a new hematoma or enlargement of an existing one, severe pain at the insertion site or in the affected extremity, chest pain, or dyspnea. While the risk of complications is low,myocardial infarction or insertion site complications may occur. These necessitate prompt intervention.

 Provide instructions about dressing changes, follow-up appointments, and potential complications prior to discharge.

Definition Why it's done Risks How you prepare What you can expect Results

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What you can expect

By Mayo Clinic staff Coronary angiogram

Heart-Healthy Living
Subscribe to our Heart-Healthy Living e-newsletter to stay up to date on heart-health topics. Sign up now During the procedure For the procedure, you lie on your back on an X-ray table. Because the table may be tilted during the procedure, safety straps may be fastened across your chest and legs. Xray cameras may move over and around your head and chest to take pictures from many angles. An intravenous (IV) line is inserted into a vein in your arm. You may be given a sedative through the IV to help you relax, as well as other medications and fluids. You'll be awake during the procedure so that you can follow instructions. Throughout the procedure you may be asked to take deep breaths, hold your breath, cough or place your arms in various positions. Electrodes on your chest monitor your heart throughout the procedure. A blood pressure cuff tracks your blood pressure and another device, a pulse oximeter, measures the amount of oxygen in your blood. You may receive medication (anticoagulants) to help prevent your blood from clotting on the catheter and in your coronary arteries. A small amount of hair may be shaved from your groin or arm where the catheter is to be inserted. The area is washed and disinfected and then numbed with an injection of local anesthetic. A small incision is made at the entry site and a short plastic tube (sheath) is inserted into your artery. The catheter is inserted through the sheath into your blood vessel and carefully threaded to your heart or coronary arteries. Threading the catheter shouldn't cause pain, and you won't feel it moving through your body. Tell your health care team if you have any discomfort. Dye (contrast material) is injected through the catheter. When this happens, you may have a brief sensation of flushing or warmth. Don't be alarmed if you feel your heart skipping beats that's a frequent occurrence during angiograms. But again, tell your health care team if you feel pain or discomfort.

The dye is easy to see on X-ray images, and as it moves through your blood vessels, your doctor can observe its flow and identify any blockages or constricted areas. Depending on what your doctor discovers during your angiogram, you may have additional catheter procedures at the same time, such as a balloon angioplasty or a stent placement to open up a narrowed artery. Having an angiogram takes about one hour, although it may be longer, especially if combined with other heart catheter procedures. Preparation and post-procedure care can add several more hours. After the procedure When the angiogram is over, the catheter is removed from your arm or groin and the incision is closed with manual pressure, a clamp or a small plug. You'll be taken to a recovery area for observation and monitoring. When your condition is stable, you return to your own room, where you're monitored regularly. You'll need to lie flat for several hours to avoid bleeding. During this time, pressure may be applied to the incision to prevent bleeding and promote healing. Sometimes, the plastic sheath that was first inserted into your blood vessel is left in place for several hours or even overnight if you've had angioplasty or stent placement. If you received anticoagulants during the procedure, removing the sheath too soon could trigger heavy bleeding. You may be able to go home the same day, or you may have to remain in the hospital for a day or longer. Drink plenty of fluids to help flush the dye from your body. If you're feeling up to it, have something to eat. Ask your health care team when you should resume taking your medications, bathe or shower, return to work, and resume other normal activities. Avoid strenuous activities and heavy lifting for several days. Your puncture site is likely to remain tender for a while. It may be slightly bruised and have a small bump. Call your doctor's office if:

You notice bleeding, new bruising or swelling at the catheter site You develop increasing pain or discomfort at the catheter site You have signs of infection, such as redness, drainage or fever There's a change in temperature or color of the leg or arm that was used for the procedure You feel faint or weak You develop chest pain or shortness of breath

If the catheter site is actively bleeding or begins swelling, apply pressure to the site and contact emergency medical services. Alternate Names for Coronary Angiogram: Angiogram Cardiac catheterization

Coronary angiography Coronary arteriography What to Expect Prior to Procedure Your doctor may order:

Blood and urine tests Electrocardiogram (ECG, EKG)-a test that records the heart's activity by measuring electrical currents through the heart muscle Stress test

Talk to your doctor about your medicines. You may be asked to stop taking some medicines before the procedure, like:

Anti-inflammatory drugs (eg, ibuprofen ) Blood thinners, like or warfarin (Coumadin) clopidogrel (Plavix) Metformin (Glucophage) or glyburide and metformin (Glucovance)

Leading up to your procedure:

Arrange for a ride to and from the procedure. The night before, do not eat or drink anything after midnight.

Anesthesia Local anesthesia will be used at the insertion site. A mild sedative may be given one hour before or through IV during the procedure. This will help you relax. Description of the Procedure During the procedure, you will receive IV fluids and medicines. An EKG will be monitoring your heart's activity. You will be awake but sedated so that you will be more relaxed. Your doctor will ask you to do basic functions such as coughing, breathing out, and holding your breath. If you feel any chest pain, dizziness, nausea, tingling, or other discomfort, tell your doctor. The area of the groin or arm where the catheter will be inserted is shaved, cleaned, and numbed. A needle will be inserted into a blood vessel. A wire will be passed through the needle and into the blood vessel. The wire will then be guided through until it reaches your heart. A soft, flexible catheter tube will then be slipped over the wire and threaded up to your heart.

The doctor will be taking x-ray pictures during the procedure to know where the wire and catheter are. Dye will be injected into the arteries of the heart. This will make the arteries and heart show up on the x-ray images. You may feel warm during the dye injection.

Once in place, the catheter can be used to take measurements. Blood pressure can be taken within the heart's different chambers. Blood samples may also be taken. Multiple xray images will be taken to look for any disease in the arteries. An aortogram may also be done at this time. This step will give a clear image of the aorta (large artery leaving the heart). Once all the tests and images are complete, the catheter will be removed. Sometimes, the doctor will perform balloon angioplasty and stenting if he finds an area in your arteries that is narrow or clogged. These are procedures that help to open narrowed arteries. Finally, a bandage will be placed over the groin or arm area. How Long Will It Take? The procedure takes about 1-2 hours. Preparation before the test will take another 1-2 hours. How Much Will It Hurt? Although the procedure is generally not painful, it can cause some discomfort, including:

Burning sensation (when skin at catheter insertion site is anesthetized) Pressure when catheter is inserted or replaced with other catheters A flushing feeling or nausea when the dye is injected Headache Heart palpitations

Pain medicine will be given when needed. Average Hospital Stay 0-1 days Postoperative Care At the Care Center

EKG and blood studies may be done. You will likely need to lie still and flat on your back for a period of time. A pressure dressing may be placed over the area where the catheter was inserted to help prevent bleeding. It is important to follow the nurse's directions.

At Home When you return home, do the following to help ensure a smooth recovery:

Do not drive for 72 hours. Do not lift heavy objects or engage in strenuous exercise or sexual activity for at least 5-7 days. Change the dressing around the incision area as instructed. Your doctor will explain to you which medicines you can take and which ones to avoid. Take medicines as instructed. Ice may help decrease discomfort at the insertion site. You may apply the ice for 15-20 minutes each hour, for the first few days. To lower your risk for further complications of heart disease, you can make lifestyle changes. These include eating a healthier diet, exercising regularly, and managing stress. Be sure to follow your doctor's instructions .

Information to ensure a good recovery

Following the Angiogram (usually during the period the nurse is removing the sheath and preventing bleeding), we will give you all the necessary information to ensure a good recovery. The following points will be made.

a). Keep the leg straight. No bending, no lifting, no carrying any bags. You will need assistance to put on shoes, socks, pants etc. When going home ensure the car seat is pushed back and the leg kept straight out in front. When you get home you need to be on bed rest this means you put the leg up on the sofa (or go to bed) and stay there for the rest of the day, only getting up to go to the toilet. If you laugh, cough or sneeze, place

your hand on your groin and press firmly where you can feel the pulse. This is to support the artery and prevent a haematoma/bleeding, (a collection of blood underneath the skin).

b). You will be required to drink 1 litre of water (preferably in addition to tea and coffee) before leaving the Angio Suite and a further two litres before going to bed that night. This is due to the fact that the dye is not very kind to the kidneys and you need to flush it out of your system as quickly as possible. Frequent sips is better than gulping the water down. It is also important that you ensure you are passing out the same amount you are taking in). The dye is clear and will not be seen in urine. Headaches and visual disturbances are common side effects of the dye and will be alleviated by taking more fluids. Diabetics may need to have a blood test following their procedure. (To ensure their kidneys are working efficiently).

c). Baths and showers should be avoided for 24hrs following the procedure and when taking the first bath or shower you should ensure the water is tepid (not too hot and not too cold).

d). You will not be able to drive for 48 hours following the angiogram.

e). You should not have any problems following the angiogram but the following may occur.

i). Bruising. This can be very black, up to the hip and down to the knee but is nothing to worry about. ii). Haematoma. You may experience a lump or swelling in the groin. This is likely to be a haematoma which is a build up of blood underneath the skin. It is not dangerous. It is simply blood escaping from a blood vessel and building up underneath the skin. However, if not dealt with quickly it can be very painful and take a very long time to resolve. If a swelling is noticed whilst in hospital inform the staff immediately. If at home, press very firmly on the area for 10 minutes gently massaging the area towards the end of that time and the blood should disperse into the tissue and be absorbed. If you are unable to disperse the haematoma or are at all concerned, please contact your GP or give the Angio Suite a ring and we will be happy to advise you. iii). Bleeding. Spotting on the pants is quite normal. It is just capillary blood from the tiny incision. We do not use dressings as research has shown that this can encourage

infection, (due to the nature of the site). However, should there be very heavy bleeding, especially if the blood is pumping from the incision site, the likelihood is that the artery has unsealed itself. Should this happen, do not panic! Lie on the floor and press as firmly as you can on the pulse in the groin whilst the person with you calls 999 after which they need take over pressing as it is unlikely you will be able to put enough pressure on lying down to stop an artery bleeding. It is EXTREMELY unlikely this will happen, but if it did you would not get to the telephone in time to get assistance yourself. (This is the reason we insist you have a person with you).

f). A letter will be faxed to your GP with the results of your angiogram a copy of which will be given to you to drop off at your GPs surgery in order to ensure that the inform is received.

g). Whether the results are negative or you require any procedures to be undertaken, you will be seen by Anne Karabardak or Louise Cohen, our Cardiac Specialist Nurses, who go through the results with you once you have had time to recover. This is a very thorough explanation giving full details of any procedures recommended as well as giving health education. If you would like a member of your family/friend to be present when this information is given, please notify your nurse after the procedure. However, they will need to park the car in the car park as this can take some time. This can be arranged when given a time for collection.

The nursing staff will contact your relative/friend an hour before you are ready for discharge.

Collection Directions/Instructions

Turn left on the roundabout, (first exit) and continue passed the main hospital entrance. After the multi storey car park there is a right turn. Take this turning and park close to the Chemotherapy Day Unit and Assessment Unit. LEAVE YOUR HAZARD LIGHTS ON. Enter through this outer doorway, follow the corridor and turn left. Follow the walk way until you reach A210 The Cardiac Dept. Report to reception and a nurse will escort your relative out to you.

Instructions for recovery/Discharge information

Precise Information given on a leaflet on discharge

After your recovery you will be ready to go home. You must be collected by car. Do not use public transport. Sit in the front passenger seat in a reclining position or alternatively in the back with your leg raised.

On reaching home, lie on a couch or bed, keeping your leg as straight as possible. Keep the puncture site dry. Do not bend down. Ask someone to remove your shoes and socks. When going up and down stairs keep your leg as straight as possible and keep your hand firmly on the puncture site. You will need to have someone to stay with you for the first 24 hours and you should not have a hot bath/shower for 24 hours. You must not drive for 48 hours. You should not return to work or do any heavy lifting or strenuous exercise for 48 hours.

You will be informed of any changes to your medication before discharge and you will be told how to care for your wound site prior to discharge.

If you have any concerns following your discharge, please contact the cardiac angiography suite on 01245 514418 from 08.00 hrs to 19.00 hrs. If you have any concerns after this time please contact your GP.

The Cardiac Rehabilitation team are happy to answer any concerns post angiogram on 01245 516376. If any bleeding occurs at home, apply flat hand pressure to the wound site and lie flat. Make arrangements to go to your local A & E as soon as possible. If severe bleeding occurs do not hesitate to dial 999.

Possible Treatment Options

Depending on the result of your angiogram there are 3 main treatment options:

1). Medication

The problem in your arteries does not require intervention or surgery, therefore it can be treated with tablets. National Institute for Health and Clinical Excellence. Mid City Place, 71 High Holborn, London, WC1V 6NA: www.nice.org.uk. 2011.

NICE Clinical guidelines 126 Issue date July 2011

2). Angioplasty or stent

The narrowing in your arteries can be treated by a balloon procedure (PCI). This is also known as an angioplasty. This is similar to the angiography procedure. However, instead of just passing dye; a fine balloon is inserted into the catheter and passed into the arteries. The balloon is inflated to widen the narrowing. Usually a small metal mesh (called a stent) is placed inside the artery to keep the artery open after it has been widened. Some patients experience angina pains through this procedure, but it should not last long. http://pain.com/library/2011/06/30-chest-pain-men/

Chest Pain in Men

June 30, 2011

Chest pain in men can have a variety of causes, from cardiovascular problems to digestive problems. Any chest pain is a good cause to seek medical attention. Chest pain may not end up having a serious cause, but it is better to be safe and have heart conditions ruled out by a doctor for sure. A heart attack, also known as a myocardial infarction, is caused by a blood clot that cuts off circulation to part of the heart muscle. Men are more likely to experience chest pain before or during a heart attack and exhibit the classic symptoms of a heart attack, including chest pain, referred pain in the arms, neck, abdomen or back, shortness of breath, sweating, dizziness and nausea. A man having a heart attack usually experiences some of these symptoms; they dont all have to occur at once to indicate a heart attack. The sooner that a person who is having a heart attack recognizes their symptoms and seeks medical attention, the better the prognosis for the patient. Chest pain can be caused by other circulatory conditions besides a heart attack, including angina, coronary spasm, pericarditis, myocarditis, and aortic dissection. A person with atherosclerotic plaques that develop and narrow the arteries may have chest pain due to decreased blood flow to the heart. If these plaques occur in the coronary arteries that supply the heart muscle itself, this is called coronary artery disease. The pain that occurs due to decreased blood flow is called angina pectoris, and this pain may feel like pressure, tightness, heaviness, squeezing or pain. Coronary spasm occurs when the coronary blood vessels that supply the heart muscle contract, causing angina pectoris. Angina is a symptom of a heart problem; anyone who is experiencing angina pectoris pain should get their heart checked by a doctor. Pericarditis and myocarditis are inflammation of the sac around the heart and the heart muscle itself, respectively. Aortic dissection is a serious condition that affects the aorta, the largest blood vessel in the body. Blood leaks between the different layers of the aorta and becomes trapped. Aortic dissection can result from uncontrolled hypertension or trauma and it requires immediate medical treatment. The symptoms of aortic dissection, such as chest pain and dizziness, may be similar to symptoms of other heart problems,

but aortic dissection may also cause sudden loss of consciousness and a different pulse reading for each arm. Hypertrophic cardiomyopathy is a problem with the heart muscle that can result in chest pain. It is often due to chronic hypertension. As the heart works harder to pump blood through blood vessels that are constricted due to atherosclerosis (decreased elasticity), over time it will grow larger and larger, becoming hypertrophic. Chest pain in men is often caused by digestive problems, such as heartburn. Heartburn occurs when stomach acid flows back up into the esophagus. The stomach is protected from its own acid by a mucus-based lining, but the esophagus is vulnerable to damage by stomach acid. This is known as acid reflux. Heartburn gets its name because it can feel like chest pain associated with heart problems due to its location. The pain can be relieved with over-the-counter antacids, but if it is a frequent problem, different treatments are required. Prescribed medications can help prevent acid reflux and heal acid damage to the esophagus. Other digestive conditions that may cause chest pain include: smooth muscle spasms in the esophagus, problems with the valve between the esophagus and the stomach, gallstones, inflammation of the gall bladder and inflammation of the pancreas. Gallstones and gall bladder inflammation are fairly common compared to the other conditions listed; gallstones can cause a lot of pain if they are large or if they block the bile duct. Pancreatitis is a serious condition that can cause abdominal or chest pain along with fever, jaundice, nausea and digestive problems. If the valve between the esophagus and stomach is not functioning properly, stomach acid may leak into the esophagus or it may be more difficult for food to get from the esophagus to the stomach. Similarly, muscle spasms in the esophagus make the process of swallowing difficult and may cause pain. Because the lungs are situated in the chest cavity, lung problems can cause chest pain as well as respiratory symptoms, such as coughing or shortness of breath. Pleurisy is pain that occurs due to inflammation of the pleura, the membranous sac that surrounds the lungs. Pleurisy can be caused by bacterial or viral infections such as pneumonia or autoimmune conditions that affect the lungs, as well as a few less common causes such as lung cancer or lung trauma. Pleurisy most often takes the form of a sharp pain that occurs when a person breathes in deeply or coughs. Pleurisy is a symptom, not a disease in itself, and it can be treated by treating the underlying cause of the pain. Chest pain due to lung involvement may also be caused by conditions such as pulmonary hypertension, a collapsed lung, asthma attacks or a blood clot in the lungs called a pulmonary embolism. Pulmonary hypertension is high blood pressure that affects the lungs. Although a collapsed lung is rare, it is a possible source of chest pain. Asthma attacks involve chest pain and difficulty breathing due to inflammation of the airways of the lungs. A pulmonary embolism is a blood clot that forms and then travels to the lungs, blocking off the blood supply to the lungs. Chest pain can also be caused by a variety of other conditions. Inflammation of the cartilage of the ribs and sternum can cause chest pain in the front of the chest; this is called costochrondritis. Pulled muscles and muscles that are sore due to chronic pain

disorders like fibromyalgia can cause chest pain. Muscles are frequently pulled when a person uses improper lifting techniques or does not warm up properly before working out. The chances of pulling a muscle decrease if the muscle is stretched properly before heavy physical exertion. Broken ribs, bruises along the rib cage and pinched nerves are also causes of chest pain. Pain from shingles, a viral infection that causes extremely painful blisters, can sometimes occur in the back and chest area. Cancerous tumors in the lungs or chest cavity may sometimes cause chest pain. Lastly, panic attacks caused by anxiety may cause chest pain. Some people who have a panic attack for the first time go to the hospital because they think they may have had a heart attack. When chest pain is involved, it is better to be safe and get it checked out. In addition, panic attacks that are severe or recurring can also be treated medically with certain medications, therapy or a combination of both. Symptoms of Chest Pain in Men

Chest pain may start in the chest, and spread to the throat, jaw, shoulder blades, or arms (left or right). A burning sensation behind your breastbone (sternum) A sour taste or a sensation of food re-entering your mouth Trouble swallowing You may have nausea, sweating, or dizziness associated with your chest pain. Pain that gets better or worse when you change your body position Pain that intensifies when you breathe deeply or cough You may experience a feeling of chest heaviness, or tightness. Chest pain may spread to the stomach, and feel like indigestion. Some people may feel terribly excruciating chest pain, and others may experience a mild discomfort. The severity of pain does not indicate how severe the damage to the heart muscle may be.