Coronary Artery Disease
Coronary artery disease (CAD) is the narrowing of the coronary arteries (the blood vessels which supply oxygen and nutrients to the heart muscle), caused by a buildup of fatty material within the walls of the arteries. This buildup causes the inside of the arteries to become rough and narrowed, limiting the supply of oxygen-rich blood to the heart muscle.

To better understand how coronary artery disease affects the heart, a review of basic heart anatomy and function follows.

The heart is basically a pump. The heart is made up of specialized muscle tissue, called the myocardium. The heart's primary function is to pump blood throughout the body, so that the body's tissues can receive oxygen and nutrients and have waste substances taken away.

Like any pump, the heart requires fuel in order to work. The myocardium requires oxygen and nutrients, just like any other tissue in the body. However, the blood that passes through the heart's chambers is only passing through on its trip through the body - this blood does not give oxygen and nutrients to the myocardium. The myocardium receives its oxygen and nutrients from the coronary arteries. The coronary arteries lie on the outside of the heart and supply oxygenated blood to the heart tissue.

When the heart tissue does not receive an adequate blood supply, it cannot function as well as it should. If the myocardium's blood supply is decreased for a length of time, a condition called ischemia may develop. Ischemia can decrease the heart's pumping ability, because the heart muscle is weakened due to a lack of food and oxygen. Think about how you may feel when you go too long without eating - you may become tired and feel weak. The heart muscle reacts in a similar way when its blood flow (food) is decreased.

Unfortunately, you may not have any symptoms of beginning coronary artery disease, yet the disease will continue to progress until sufficient artery blockage exists to cause symptoms and problems. Some symptoms of coronary artery disease include chest pain, fatigue, palpitations, and shortness of breath. If the blood supply to the heart muscle continues to decrease as a result of increasing obstruction of a coronary artery, a myocardial infarction, or heart attack, may occur. If the blood flow cannot be restored to the particular area of the heart muscle affected, the tissue may actually die, just as you could die without food.

Fortunately, the technology is available to restore blood flow to heart tissue when the coronary artery blockages are diagnosed. One of several diagnostic procedures used to diagnose and evaluate coronary artery disease is cardiac catheterization.

From the lungs, the blood flows back into the left atrium, is pumped into the left ventricle, then is pumped through the aorta out to the rest of the body and the coronary arteries. When the atria are pumping, the ventricles are relaxed in order to receive the blood from the atria. Once the atria have pumped their entire blood load into the ventricles, they relax while the ventricles pump the blood out to the lungs and to the rest of the body.

In order to keep the blood flowing forward during its journey through the heart, there are valves between each of the heart's pumping chambers:

• tricuspid valve - located between the right atrium and the right ventricle.
  
• pulmonary (or pulmonic) valve - located between the right ventricle and the pulmonary artery.
  
• mitral valve - located between the left atrium and the left ventricle.
  
• aortic valve - located between the left ventricle and the aorta.
  

If the heart valves become damaged or diseased, they may not function properly. Dysfunction of heart valves may be either stenotic (stiff) or insufficient (leaky). When one (or more) valve(s) becomes stiff, or stenotic, the heart muscle must work harder to pump the blood through the valve. Some reasons why heart valves become stenotic include infection (such as rheumatic fever or staph infections) and aging. If one or more valves become leaky, or insufficient, blood leaks backwards, which means that less blood is pumped in the proper direction.

Valvular heart disease may cause the following symptoms:

• dizziness
• chest pain
• breathing difficulties
• palpitations
• edema (swelling) of the feet, ankles, or abdomen
• rapid weight gain due to fluid retention

Congestive Heart Failure
Congestive heart failure (CHF) is a condition that occurs when the heart is unable to pump blood sufficiently. Despite its name, a diagnosis of CHF does NOT mean the heart is about to stop beating. The term "failure" refers to the fact that the heart muscle is failing to pump blood in the normal manner because it has become weakened.

Some causes for CHF, or weakening of the heart muscle, may include, but are not limited to, the following:

• heart attack (Also called myocardial infarction, or MI.)
  
• high blood pressure (hypertension)
  
• valvular heart disease
  
• congenital (present at birth) heart conditions
  
• cardiac arrhythmias (irregular heartbeats)
  
• pulmonary hypertension (elevated blood pressure within the lung's blood vessels)
  
• alcoholism or drug abuse
  
• chronic lung diseases, such as emphysema or chronic obstructive pulmonary disease
  
• cardiomyopathy (an enlargement of the heart muscle)
  
• anemia (low red blood cell count)

• fatigue
  
• edema of the feet, ankles, and/or abdomen
  
• frequent cough
  
• inability to lie flat for any length of time; having to sleep on two or more pillows
  
• chest pain
  
• palpitations
  
• markedly decreased exercise tolerance
  
• dizziness
  
• shortness of breath
  
• loss of appetite

CHF is most often treated medically. That is, the patient with CHF is followed closely by the physician and treated with several different types of medications that are used to accomplish the following:

• strengthen the heart
  
• relax the blood vessels so that the heart does not have to work as hard
  
• remove extra fluid from the body
  
• replace certain minerals which may be removed from the body by diuretics (medication used to remove extra fluid from the body)

In addition, diet modification is used to help decrease sodium (salt) and fluids in the body. Other important components of CHF treatment include:

• elimination of caffeine and tobacco
  
• an exercise program tailored for the patient's activity tolerance
  
• daily monitoring of body weight
  
• ongoing patient education to assist the CHF patient and his/her family to maintain the highest possible level of functioning and quality of life

In cases of severe CHF, heart transplantation may be an option. Many factors are considered when assessing a patient for heart transplant, so it may not always be an option for any given patient. Evaluation for heart transplant is a very thorough, detailed process. This detailed process is necessary because a donor heart must be found in order for a heart transplant to be performed.

Congenital Heart Disease
Congenital heart disease refers to one or more of several conditions that are present at birth ("birth defects"). Some congenital heart conditions include the following:

• atrial septal defect
  With this condition, there is a hole between the two atria (upper chambers of the heart). Although blood from the left atrium flows into the right atrium through this defect, there may be few, if any, symptoms present in infants and children - except for a possible heart murmur (an abnormal sound heard through the stethoscope when listening to the heart).
  
• ventricular septal defect
  With this condition, a hole occurs between the two ventricles (lower chambers of the heart). Because of this hole, blood from the left ventricle flows back into the right ventricle, due to higher pressure in the left ventricle. This causes an extra volume of blood to be pumped into the lungs by the right ventricle, which can create congestion in the lungs.
  
• patent ductus arteriosus (PDA)
  In the fetus, a hole occurs naturally between the pulmonary artery and the aorta. However, shortly after birth, this hole closes on its own. Sometimes, this hole does not close, which means that oxygenated blood from the aorta returns back to the lungs through the pulmonary artery, causing congestion in the lungs, an increased workload on the heart, and eventually an enlarged heart (in some cases).
  
• obstruction defect
  This general term refers to several different congenital conditions that cause an obstruction in the flow of blood through the heart. Obstruction defects include:
  
  
  • aortic stenosis - a stiffening of the aortic valve (the valve between the left ventricle and the aorta).
    
  • pulmonary stenosis - a stiffening of the pulmonary (or pulmonic) valve (the valve between the right ventricle and the pulmonary artery).
    
  • bicuspid aortic valve - a defect in the aortic valve, in which there are only two leaflets (flaps) in the valve instead of the normal three leaflets.
    
  • subaortic stenosis - a narrowing of the left ventricle just below the aortic valve.
    
  • coarctation of the aorta - a narrowing or constriction of the aorta, which obstructs blood flow from the heart to the rest of the body tissues.
    
    
• tetralogy of Fallot
  In this condition, there are actually four separate defects occurring at the same time: ventricular septal defect, pulmonary stenosis, overriding aorta (the outflow tract of the aorta begins just above the ventricular septal defect instead of at the normal location in the left ventricle), and right ventricular hypertrophy (enlargement of the muscle of the right ventricle).
  
• transposition of the great vessels
  In this condition, the outflow tracts of the aorta and the pulmonary artery are switched during fetal development. This means that unoxygenated blood flows out to the body through the pulmonary artery and oxygenated blood flows back into the lungs through the aorta. By itself, this condition cannot sustain life after birth. However, there are usually accompanying defects that permit some oxygenated blood to get out to the body tissues.
  
• tricuspid atresia
  In this condition, the tricuspid valve between the right atrium and right ventricle is missing. By itself, this would mean that no blood can be pumped into the lungs to receive oxygen; however, there are usually accompanying defects that allow some blood to go to the lungs.

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What is Cardiac Catheterization?

In cardiac catheterization (often abbreviated as cardiac cath), a very small hollow tube, or catheter, is advanced from a blood vessel in the groin through the aorta into the heart. Once the catheter is in place, several diagnostic techniques may be used. The tip of the catheter can be placed into various parts of the heart to measure the pressure within the chambers. The catheter can be advanced into the coronary arteries and a dye injected into the arteries. By the use of fluoroscopy (a special type of x-ray), the physician can tell where any blockages in the coronary arteries are located as the dye moves through the arteries. A small sample of heart tissue can be obtained (called a biopsy) during the procedure to be examined later under the microscope for abnormalities.

You are awake during the procedure, although you will receive a small amount of sedating medication prior to the procedure.

Due to advances in knowledge, technology, and techniques, cardiac cath is often performed on an outpatient basis, meaning that the procedure is done early in the day and you may go home the same day. However, catheterization may be done on patients who are already hospitalized and thus will remain in the hospital after the procedure. Also, some patients who were at home before the procedure may be admitted to the hospital after the procedure in certain circumstances such as the occurrence of complications during or after the procedure, balloon angioplasty done during the procedure, or other reasons.

Reasons for the Procedure
Your physician may schedule you for a cardiac catheterization if you have recently had an episode(s) of one or more of the following cardiac symptoms:

• chest pain
• shortness of breath
• dizziness
• fatigue

Also, if a screening examination such as an EKG suggests a possibility of some type of heart disease process that needs to be explored further , a cardiac cath may be ordered by your physician.

Other reasons for the cath procedure include evaluation of myocardial perfusion (blood flow to the heart muscle) after the following:

• heart attack
  
• heart bypass surgery
  
• coronary angioplasty (the opening of a coronary artery using a balloon or other method)
  
• stent (a tiny expandable metal coil placed inside the artery to keep the artery open) placement

There may be other reasons for your physician to recommend a cardiac catheterization.

Risks of the Procedure
Possible risks associated with of cardiac catheterization include, but are not limited to, the following:

• bleeding at the catheter insertion site (usually the groin, but the arm may be used in certain circumstances)
  
• blood clot or damage to the blood vessel at the insertion site
  
• stroke (brain attack) or heart attack due to dislodging of a plaque into the blood circulation during the procedure (rare occurrence)
  
• infection at the catheter insertion site
  
• pneumothorax (collapsed lung) due to misplaced catheter
  
• allergic reaction to the dye
  
• kidney failure related to the dye
  
• cardiac dysrhythmias

In addition, cardiac catheterization should not be performed on a woman who is pregnant or thinks she may be pregnant.

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What to Expect

What to Do the Night Before

1. Your physician will give you instructions regarding how to schedule the procedure at the clinic or hospital. Make sure you follow all instructions carefully so that everything will be in order at the scheduled time.
   
   
2. Do not eat or drink anything after midnight before your procedure. Your physician will most likely tell you to take your regular medications with small sips of water the morning of your procedure; however, certain medications may be omitted if the physician instructs you to do so. If your procedure is scheduled for later in the day, you may be able to have a clear liquid breakfast, such as juice and coffee or tea, early in the morning prior to your procedure. Ask your physician about this if your procedure is scheduled for mid-day or later in the afternoon.
   
   
3. Pack an overnight bag, as you will spend the night in the hospital following the procedure. Include your pajamas or gown, a robe, slippers, a change of underwear, and toilet articles such as toothbrush, toothpaste, deodorant, etc.
   
   
4. Arrange to have someone drive you home from the hospital once you are discharged, as you will not be allowed to drive for a few days following the procedure.
   
   
5. Bring a list of all medications you are currently taking.
   
   
6. If your physician already knows that you have valve disease, you will be given an antibiotic to take before the procedure.

Diagnostic Tests Before the Procedure
Several procedures or tests are usually completed at some point prior to cardiac catheterization. These tests may include, but are not limited to, the following:

• electrocardiogram (ECG or EKG) - a test that records the electrical activity of the heart, shows abnormal rhythms (arrhythmias), and detects heart muscle damage.
  
• blood work, which may include, but is not limited to:
  
  • blood count
    
  • cardiac isoenzymes (to check for damage to the heart muscle)
    
  • electrolytes (such as potassium, calcium, and sodium)
    
  • bleeding studies (to assess the blood-clotting process)
    
  • kidney function tests
    
    
• chest x-ray - a diagnostic test that uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film.
  
• myocardial perfusion study - a type of nuclear scan that uses very small amounts of radioactive materials (radiopharmaceuticals) to assess the heart's function and structure; two common studies are radionuclide angiography and myocardial perfusion scan.
  
• echocardiography - a noninvasive (the skin is not pierced) procedure that assesses the heart's function and structures with ultrasonic sound waves.
  

Scheduling/Registration Information
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Where the Procedure is Done
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Who Performs the Procedure
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Directions to the Hospital
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It is important to arrive at your scheduled time. Your procedure may not begin immediately due to varying lengths of procedures scheduled before your procedure. You will be updated as frequently as possible.

Preparing for the Procedure in the Hospital
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• Description of IV, site preparations, and medications that may be administered - Upon arrival, you will be asked to remove your clothing and put on a hospital gown. You may wear socks if your feet get cold, and you may also wear your glasses, dentures, and/or hearing aid if you use them. Any other jewelry or valuables will be given to your family for safe-keeping.
  
  An intravenous (IV) line will be started in your hand or arm prior to the procedure for injection of medication and to administer IV fluids, if needed. The area where the catheter will be inserted, either the groin or arm, will be shaved and cleaned with antiseptic soap. You will receive a sedative medication in your IV before the procedure to help you relax. You may wear your glasses, dentures, or hearing aid if you use any of these. The pulses in your feet will be checked and the location where the pulses are felt will be marked on the skin with a marker. This is done in order to be able to compare the strength of these pulses after the procedure.
  

• Consent forms - Prior to receiving your sedative medication, you will be asked to sign a consent form after your physician explains the procedure, expected results, and possible complications and risks. Please read through the form carefully. If you have questions about anything in the consent form, please ask your physician to explain the information to you.
  
  
• Description of research studies - You may be asked before or after your procedure if you would like to participate in a research study. We believe research is important to our continued effort to improve care for the patients of tomorrow. However, you are not obligated to participate in any study, nor will your medical care be affected by your decision. Nonetheless, we would like you to make an informed decision. Should you have any questions about the research study you may decide to participate in, please feel free to ask your physician or the research associate during your visit.

During the Procedure

• Description of the room, monitoring devices, positions, and equipment that will be used - From the preparation area, you will be taken to the cath lab, the room where the cardiac catheterization procedure is performed, on a stretcher. The room will be cool due to the equipment in use.

  You will be assisted onto a cushioned table. The nurses and technicians will connect you to various types of monitoring equipment in order to assess your heart rate and rhythm, blood pressure, and oxygen levels during the procedure. You are encouraged to ask questions if you have them. You will lie flat on your back during the entire procedure. There will be several monitor screens in the room, showing your vital signs (EKG, heart rate, blood pressure, breathing rate, and oxygen level), the images of the catheter being moved through the body into the heart, and the structures of the heart as the dye is injected.
  
  The cath lab is a procedure area, so many hospital personnel in the room will wear gowns, masks, and caps. The physician and assistants actually performing the procedure will wear sterile gloves. A large x-ray camera will be above the table to make pictures of the procedure.
  

• Anesthesia - As stated above, you may be given a sedative medication in your IV prior to the procedure to help you relax. However, you will likely remain awake during the procedure.

• Basic description of the procedure:
  
  
  • Once the monitoring equipment has been connected, the cath site (groin or arm) will again be cleaned with antiseptic soap.
    
  • The insertion area will be covered with sterile towels and a sheet.
    
  • A numbing medication (lidocaine or xylocaine) will be injected into the skin at the cath site. You may feel some stinging at the site for a few seconds after the numbing medication is injected.
    
  • Once the numbing medication has taken effect, a sheath, or introducer, is inserted into the blood vessel. This is a plastic tube through which the catheter will be inserted into the blood vessel and advanced into the heart. If the arm is used, a small incision (cut) may be made to expose the blood vessel for insertion of the sheath.
    
  • It will be very important for you to remain still during the procedure so that the catheter placement is not disturbed and to prevent damage to the cath site.
    
  • The physician advances the catheter through the blood vessels into the heart. This is done by watching the catheter on the monitor and guiding it into the proper structures. The room will be dim, so that the monitors can be seen by the physician and staff.
    
  • Once the catheter is in place, dye is injected through the catheter to visualize the heart and the coronary arteries. It is possible that you may feel a brief sensation of warmness just after the dye is injected, but this sensation is temporary and will soon pass.
    
  • Your physician will observe the coronary arteries after the x-ray dye injection on an x-ray monitor that resembles a TV screen. You may also be able to watch the monitor screen at this time. During this time, you may be instructed to take in a deep breath and hold it for a few seconds.
    
  • After the x-rays are taken of the heart and coronary arteries, the catheter is removed.
    
  • The physician (or an assistant) will hold pressure on the cath site for about 15 to 20 minutes, so that the blood can begin to form a clot at the site and stop bleeding. Once the physician (or assistant) is satisfied that bleeding has stopped, a very tight bandage will be placed on the site. A sandbag may be placed on top of the bandage for additional pressure on the site, especially if the site is the groin.
  • You will be assisted to slide from the table onto a stretcher so that you can be taken to the recovery area. NOTE: You will not be allowed to bend your leg nearest the cath site, if the insertion was done in the groin, for several hours. To help you remember to keep your leg straight, the knee of the affected leg will be covered with a sheet and the ends will be tucked under the mattress on both sides of the bed to form a type of loose restraint.
    
    
• Procedure time - The cath procedure itself will last about an hour, depending on how long it takes to obtain adequate diagnostic information. If the physician decides to do an additional procedure to open one or more clogged coronary arteries (percutaneous transluminal coronary angioplasty, or PTCA), the procedure will last longer than two hours.

After the Procedure

• Recovery process - After the cath procedure has been completed, you will be taken on a stretcher to a recovery area.

  You will be closely monitored by a nurse during the recovery period. Your blood pressure, heart rate and rhythm, and breathing will be assessed frequently. The nurse will also check the blood circulation in the leg or arm used for the catheter insertion, and assess the dressing on the cath site for bleeding. You should immediately inform your nurse if you feel any chest pain or tightness, or any other pain. You should also tell your nurse about any feelings of warmth, bleeding, or pain at the cath site in your leg or arm.

  The sheath, or introducer, is in an artery and thus will need to remain in the cath site for approximately four to six hours, in order to allow the effects of blood-thinning medication given during the procedure to wear off. You will need to lie flat during this time. If you become uncomfortable in this position, your nurse may give you medication to make you more comfortable.
  
  At the appropriate time, the sheath will be removed from the groin or arm. After the sheath is removed, pressure will be applied directly on the site either manually or with a clamp-type device for about 20 minutes. After bleeding has stopped completely with the pressure application, a tight dressing will be applied on the site. You will continue to lie in bed for a specified period, at least two hours or longer. It is very important that you keep your leg or arm with the catheter site straight during this period.

  After the sheath has been removed, you may be given a light meal, such as a sandwich and fruit. You will be encouraged to drink fluids as much as possible to help flush the x-ray dye from your system. The effects of increased fluid intake and the x-ray dye will cause you to urinate frequently; however, you will need to use a bedpan or urinal during this time so that your affected leg or arm will not be bent. You may require assistance from your nurse, so do not hesitate to ask for help.

  After the specified period of bed rest has been completed, you may get out of bed. The nurse will assist you the first time you get up, and will check your blood pressure while you are lying, sitting, and standing.
  

• Length of stay - If the procedure is done on an outpatient basis, you will be allowed to leave after you have completed the recovery process - usually about six to eight hours after the procedure is finished. If an angioplasty is done during the procedure, or if complications occur during or after the procedure, you will spend the night in the hospital.
  
  
• Average recuperation time - You will most likely feel tired for a day or so after the procedure. The catheter site in your leg or arm may be sore for a few days. You may have other pain or discomfort for a day or so due to lying still for a long period of time during the procedure and the recovery period.
  

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Discharge Instructions

Medications
Your physician may order medication(s) for you to take after your cath procedure. Prior to your leaving the hospital, you will be given a list of medications that are being ordered by your physician, and your nurse will explain the dose, medication schedule, and possible side effects. You will also be given prescriptions to take to your pharmacy.

Diet
Your diet recommendations will depend on the results of your procedure. Your nurse will tell you what type of diet your physician recommends. If you have questions about any dietary changes, ask if dietitian is available to assist you in understanding your new food plan. You will be given materials to help you plan your meals.

Activity
Your physician will instruct you as to when you can return to your usual daily routine. The period of time before returning to normal activities may range from two to three days to a longer period, depending on whether you have had heart damage from a heart attack. Your physician will give you specific instructions. In addition, you should not do any lifting until your physician advises you to do so.

Sexual Activity
You may be able to resume sexual activity within seven to 10 days, unless your physician instructs you differently.

Bath Care
Once you are out of bed, you will most likely be allowed to take a shower. Some precautions related to taking a shower for the first few days after a cath procedure may include, but are not limited to, the following:

• You may use your usual soap and water. However, do not scrub or apply pressure at the site in the groin or arm where the catheter was inserted.
  
• Remember to pat the catheter site dry with a towel and do not rub.
  
• You should not take a tub bath for the period of time your physician specifies, which may be for a week after your procedure. Sitting in a tub of water, which includes a hot tub, can cause infection at the catheter site.
  

Site Care

• Pat the catheter site dry after taking a shower, instead of rubbing.
  
• Keep the site clean and dry by placing a Band-aid^® on it until it is healed.
  
• Change the Band-aid^® every day until healing occurs.
  
• Check the site at least once a day. Report any additional bruising, swelling, drainage, redness, or warmth at the site to your physician immediately.
  
• It is not unusual to see bruising around the catheter site, or even a raised, hard, bruised area, called a hematoma. Bruising and hematomas usually fade away within a week or two.
  

Driving a Vehicle
Your physician will give you instructions as to when you may resume driving. It is very important that you make arrangements for someone to drive you home from the hospital following your procedure.

Returning to Work
Your physician will give you instructions as to when you may return to work. The type of work you do, as well as your health condition and degree of recovery will affect the physician's decision as to how long you will need to remain out of work.

Office Visit
Your physician will schedule a follow-up office visit within a week to a month after your procedure. Your condition and the extent of any heart damage will determine the length of time until your appointment.

Warning Signs / Symptoms to Monitor
The presence of any of the following warning signs should be reported to your physician immediately:

• chest pain/pressure, nausea and/or vomiting, profuse sweating, dizziness and/or fainting
  
• any symptoms in the leg or arm where the catheter was inserted, such as pain, coolness, numbness, and/or weakness
  
• bleeding from the catheter site in the groin or arm, increased pain at the site, or increased bruising and/or hematoma
  

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