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Abstract
The addition of sodium to nonionic contrast media has reduced the incidence of arrhythmias in animal models. The influence on cardiac function and safety of sodium addition to the nonionic contrast medium iohexol (Omnipaque) was studied in a randomized, double-blind trial in patients undergoing cardioangiography. Fifty-nine patients received iohexol 350 mg I/ml with NaCl 28 mmol/l and 58, iohexol only. ECG changes after contrast injections were evaluated with continuous computerized dynamic vectorcardiography (VCG). QRS-vector difference (QRS-vd), which reflects changes in the QRS-complex, was chosen as the main parameter. Both contrast media caused changes in the QRS-complex, but there was no significant difference between the two. No serious arrhythmias were observed. Both contrast media were well tolerated. No beneficial effects from enriching iohexol with sodium were found. VCG was found to be a valuable tool in the study of contrast medium-induced ECG changes.
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Bååth L, Almén T, Öksendal A. Oxygen Saturation of the Low Osmolar Contrast Media Iohexol, Ioxaglate and Iodixanol. Acta Radiol 2016. [DOI: 10.1177/028418519003100520] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
During coronary angiography the exchange of blood with a contrast medium solution causes a period of hypoxia. To investigate whether oxygen saturation of the contrast medium could be beneficial, low osmolar contrast media were infused without and with oxygen saturation into the coronary arteries of the isolated rabbit heart. Iohexol (150–300 mg I/ml, without NaCl or with 20–30 mM NaCl), iodixanol (320 mg I/ml, contains 24 mM NaCl) and ioxaglate (160 mg I/ml, contains 75 mM Na+) were infused without and with oxygen saturation. The decrease in contractile force (CF) of the heart, from the contrast medium solutions, was reduced when the solutions were saturated with oxygen. Oxygen saturation of iohexol (350 mg I/ml, without or with 10 mM NaCl) did not change the frequency of ventricular fibrillations (VF). Low osmolar contrast media, when saturated with oxygen, thus caused a reduced decrease in CF without changing the frequency of VF. This might be beneficial in clinical cardioangiography by reducing the adverse effects from the media.
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Wilson RF. Coronary Angiography. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Wilson RF, White CW. Coronary Angiography. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Ogawa T, Fujii S, Urasawa K, Kitabatake A. Effects of nonionic contrast media on platelet aggregation: assessment by particle counting with laser-light scattering. JAPANESE HEART JOURNAL 2001; 42:115-24. [PMID: 11324800 DOI: 10.1536/jhj.42.115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Intravascular radiographic contrast media used in angiography, particularly nonionic contrast media, may cause activation of platelets. This study was designed to determine which properties of nonionic contrast media were potentially responsible for this action. Platelet aggregation after adenosine diphosphate stimulation was studied in the platelet rich plasma obtained from 37 patients who underwent left ventriculography using the highly sensitive method of particle counting with laser-light scattering. Platelet activation by contrast media was studied in the platelet rich plasma from healthy volunteers using flow cytometric analysis to detect platelet degranulation as P-selectin expression. There was a significant decrease in platelet aggregation in patients injected with ioxilan or iomeprol compared with patients injected with iohexol. There was a significant increase in P-selectin expression with the three groups of contrast media compared to control. The platelet activation with ioxilan or iomeprol was significantly less compared to the activation with iohexol. The comparison showed that previous generalization regarding platelet activation by nonionic contrast media might not be valid. It is presumed that the higher osmolality of iohexol may contribute to the increase in platelet aggregation and activation.
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Affiliation(s)
- T Ogawa
- Department of Cardiovascular Medicine, Hokkaido University School of Medicine, Sapporo, Japan
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Barrett BJ, Parfrey PS, Morton BC. Safety and criteria for selective use of low-osmolality contrast for cardiac angiography. Med Care 1998; 36:1189-97. [PMID: 9708591 DOI: 10.1097/00005650-199808000-00007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Recommendations to restrict low-osmolality contrast to high-risk patients having cardiac angiography have been challenged because of safety and uncertainty about selection criteria. The authors document frequency and severity of adverse events with diagnostic cardiac angiography under the influence of guidelines for selective use of low-osmolality contrast in high-risk patients and refine high-risk criteria. METHODS Subjects of this prospective cohort study were 7,448 unselected patients having diagnostic cardiac angiography in St. John's, Newfoundland or Ottawa, Ontario. Measures included prespecified risk factors, procedure, contrast, and adverse events such as death within 24 hours, myocardial infarction, stroke, arrhythmias, hypotension, and anaphylactoid reactions. RESULTS Patients were similar at both sites. Fourteen point two percent received low-osmolality nonionic agents in St. John's. Thirty-four point one percent received low-osmolality (mostly ionic) media in Ottawa. Overall adverse event rates were similar at both sites: death, 0.07%; myocardial infarction or stroke, 0.03%; moderate events, 2%; and mild events, 16.8%. Event rates were low in those given high-osmolality media: death, 0.02%; myocardial infarction or stroke, 0.24%; moderate events, 1.6%; and mild events, 18%. The risk with cardiogenic shock and prior severe reaction to contrast could not be examined, but otherwise only current heart failure and markers of recent ischemia were associated with events after high-osmolality media. CONCLUSIONS Clinicians, using guidelines, can identify high-risk patients and should be able to safely limit use of low-osmolality media to them.
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Affiliation(s)
- B J Barrett
- Clinical Epidemiology Unit, Memorial University of Newfoundland, St. John's.
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Jost S, Hausmann D, Lippolt P, Gerhardt U, Lichtlen PR. Influence of radiographic contrast agents on quantitative coronary angiography. Cardiovasc Intervent Radiol 1997; 20:5-9. [PMID: 8994717 DOI: 10.1007/s002709900101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE Quantitative angiographic studies on the vasomotility of epicardial coronary arteries are gaining increasing relevance. We investigated whether radiographic contrast agents might influence coronary vasomotor tone and thereby the results of such studies. METHODS Coronary angiograms were taken in 12 patients with coronary artery disease at intervals of 5, 3, 2, and 1 min with the low-osmolar, nonionic contrast agent iopamidol 300, and were repeated at identical intervals with the high-osmolar, ionic agent diatrizoate 76%. RESULTS Quantitative cine film analysis demonstrated no significant diameter changes in angiographically normal and stenotic coronary arteries with iopamidol. With diatrizoate, however, normal segments were dilated 2% +/- 2% (p < 0.01) after 2 min and 10% +/- 3% after the 1 min interval (p < 0.001). Stenoses showed no uniform responses to diatrizoate. CONCLUSION Low-osmolar, nonionic contrast agents should be preferred for quantitative angiographic studies on epicardial coronary vasomotility. When using ionic contrast agents, injection intervals of at least 3 min are required.
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Affiliation(s)
- S Jost
- Division of Cardiology, Hannover Medical School, Germany
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Werner GS, Schmidt T, Scholz KH, Figulla HR, Kreuzer H. Comparison of hemodynamic and Doppler echocardiographic effects of a new low osmolar nonionic and a standard ionic contrast agent after left ventriculography. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1994; 33:11-9. [PMID: 8001095 DOI: 10.1002/ccd.1810330104] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The hemodynamic effects of a new nonionic low osmolar contrast agent (iomeprol) during left ventriculography (LC) was compared with a standard ionic contrast agent (meglumine diatrizoate) in a randomized double blind study in 30 patients with suspected coronary artery disease and normal systolic ventricular function. LV diastolic function was assessed by Doppler echocardiographic recording of the transmittal filling curve and by intraventricular tip-manometry before and within 30 sec of the LC. In the group receiving the ionic contrast agent the systolic pressure fell from 126 +/- 23 to 111 +/- 18 mmHg (P < 0.05), and heart rate increased from 64 +/- 9 to 71 +/- 11 min-1 (P < 0.05), while no such effects were observed with the nonionic contrast agent, indicating differences in the vasodilator properties. The latter caused an increase of the peak early Doppler velocity (52 +/- 11 to 62 +/- 14 cm/sec; P < 0.05). After the ionic contrast agent, the effect on the peak early Doppler velocity was less pronounced, probably due to an interaction with the known depressant effect of the increase in heart rate on the early Doppler velocity. In both groups the left ventricular end diastolic pressure was increased from 7 +/- 3 to 10 +/- 4 mmHg. No significant effects on peak-dp/dt and dp/dt were observed in either group. The nonionic contrast agent iomeprol had no significant effect on systolic arterial pressure and heart rate in contrast to the ionic contrast agent, probably due to a less pronounced vasodilator effect. Despite these differences of the global hemodynamic response, there were similar effects of both contrast agents on LV diastolic filling.
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Affiliation(s)
- G S Werner
- Department of Cardiology, Georg-August-University Göttingen, Germany
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Matthai WH, Kussmaul WG, Krol J, Goin JE, Schwartz JS, Hirshfeld JW. A comparison of low- with high-osmolality contrast agents in cardiac angiography. Identification of criteria for selective use. Circulation 1994; 89:291-301. [PMID: 8281660 DOI: 10.1161/01.cir.89.1.291] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Controversy exists as to whether low-osmolality radiographic contrast agents, which have less detrimental pharmacological effects but are considerably more expensive than high-osmolality agents, should be used universally or only for selected high-risk patients. METHODS AND RESULTS A randomized, double-blind study was used to compare the frequency and severity of adverse events in 2245 consecutive patients undergoing diagnostic cardiac angiography. Two thousand one hundred sixty-six patients were successfully randomized to either iohexol, a low-osmolality contrast agent, or diatrizoate (as Hypaque 76), a high-osmolality agent. The end point event included clinically important adverse events (which jeopardized the patient or required aggressive treatment), contrast agent-related procedure abbreviations, and conversion to open-label contrast agent. Clinically important end point events were associated with increased age, New York Heart Association functional class, left ventricular end-diastolic pressure, arteriovenous oxygen difference, severity of coronary artery disease, and history of a previous reaction to contrast agent. End point events were less frequent in patients receiving iohexol (2.6% versus 4.6%; adjusted odds ratio, 1.59; 95% confidence interval, 0.97-2.60; P = .07). The difference in event frequency between iohexol and diatrizoate was confined to the highest-risk quartile of the patient population. An algorithm was developed to classify patients as being at high or low risk for an event based on patient age, New York Heart Association class, history of a prior contrast reaction, and left ventricular end-diastolic pressure. Application of this algorithm for selective use of low-osmolality agents only for high-risk patients to a theoretical population of 1000 patients reduced contrast agent costs 66% without increasing the frequency of contrast agent-related adverse events. CONCLUSIONS The advantages of low-osmolality contrast agents are clinically important in patients with severe heart disease but are not in less ill patients. Universal use of low-osmolality agents for cardiac angiography in an unselected population is not necessary. Appropriately guided selective use of low-osmolality contrast agents is feasible and has the potential to reduce cost substantially without compromising safety or effectiveness.
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Affiliation(s)
- W H Matthai
- Cardiac Catheterization Laboratory, University of Pennsylvania School of Medicine, Philadelphia
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Powe NR, Davidoff AJ, Moore RD, Brinker JA, Anderson GF, Litt MR, Gopalan R, Graziano SL, Steinberg EP. Net costs from three perspectives of using low versus high osmolality contrast medium in diagnostic angiocardiography. J Am Coll Cardiol 1993; 21:1701-9. [PMID: 8496540 DOI: 10.1016/0735-1097(93)90390-m] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES We conducted an economic analysis to assess the extent to which a reduction in adverse drug reactions induced by low osmolality compared with high osmolality contrast media during diagnostic angiocardiography would result in savings to hospitals, society and third-party payers that would offset the substantially higher price of low osmolality contrast medium. BACKGROUND Substitution of low osmolality for high osmolality contrast media in the approximately 1 million diagnostic angiocardiographic procedures performed each year in the United States could substantially increase health care costs. Cost-effectiveness estimates should include savings that might occur through reduced costs of managing adverse drug reactions. METHODS In a randomized clinical trial of 505 persons under-going diagnostic angiography with either high osmolality or low osmolality contrast medium, we measured and compared 1) material costs of contrast media, and 2) costs from three perspectives of incremental resources used to manage contrast-related adverse drug reactions. We also performed sensitivity analyses to examine the effect of different assumptions with regard to relative risk, absolute risk and costs of adverse drug reactions on estimates of net cost of use of high osmolality and low osmolality contrast media. RESULTS One-hundred thirty-seven (54.2%) of 253 patients receiving high osmolality contrast medium and 44 (17.5%) of 252 patients receiving low osmolality contrast medium experienced adverse drug reactions. The average cost (from society's perspective) of resources used to manage adverse drug reactions per patient undergoing angiography was significantly (p = 0.0001) greater for high osmolality (mean $249) versus low osmolality (mean $92) contrast medium. Differential costs (from the hospital's perspective) were $67 greater for high osmolality contrast medium. Charges and professional fees (from the payer's perspective) were $182 greater for high osmolality (mean $312) than for low osmolality (mean $130) contrast medium (p = 0.42, NS). The higher differential and average costs of managing adverse drug reactions with high osmolality contrast medium offset 33% and 75%, respectively, of the $207 difference in mean material costs, but these estimates are sensitive to infrequent high cost cases. CONCLUSIONS Although low osmolality contrast medium is not cost-saving in diagnostic angiocardiography, its higher price is partially offset by lower management costs of adverse drug reactions. The cost offset for the hospital is lower than that for society and may not be realized by third-party payers. These methods and results may be useful in establishing clinical and payment guidelines for use of alternative contrast media in diagnostic angiocardiography.
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Affiliation(s)
- N R Powe
- Department of Medicine, Johns Hopkins University School of Medicine, Maryland
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Ritchie JL, Nissen SE, Douglas JS, Dreifus LS, Gibbons RJ, Higgins CB, Schelbert HR, Seward JB, Zaret BL. Use of nonionic or low osmolar contrast agents in cardiovascular procedures. American College of Cardiology Cardiovascular Imaging Committee. J Am Coll Cardiol 1993; 21:269-73. [PMID: 8417070 DOI: 10.1016/0735-1097(93)90747-o] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Low osmolar contrast agents produce less adverse electrophysiologic and hemodynamic alterations during cardiac catheterization. The nonionic agents probably reduce the risk of provoking myocardial ischemia during coronary arteriography or ventriculography. Patients also report less subjective sensation of discomfort during administration of low osmolar agents for cardiovascular procedures. However, nonionic agents have not been proved to reduce the incidence of several serious complications of cardiac catheterization, including acute renal failure and anaphylactoid reaction. Although evidence is inconclusive, there may be an increased risk of thromboembolic complications during cardiac catheterization when certain low osmolar nonionic agents are administered. Nonionic contrast agents have not been definitely proved to reduce the risk of death after cardiac catheterization.
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Hill JA, Grabowski EF. Relationship of anticoagulation and radiographic contrast agents to thrombosis during coronary angiography and angioplasty: are there real concerns? CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1992; 25:200-8. [PMID: 1571975 DOI: 10.1002/ccd.1810250306] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Radiographic contrast agents are essential for the performance of coronary angiography and angioplasty. Historical data show that thrombosis-related events have occurred since coronary angiography has been performed. Newer non-ionic agents have been shown to be safer than conventional high osmolar ionic agents especially in high risk patients, but concern has been raised about a potentially increased risk of thrombosis with the use of these agents. A review of basic and clinical evidence for this perception does not support the view that an increase in thrombosis-related events has occurred as a results of non-ionic contrast media use in coronary angiographic procedures.
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Affiliation(s)
- J A Hill
- Division of Cardiology, University of Florida College of Medicine, Gainesville 32610
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Barrett BJ, Parfrey PS, Vavasour HM, O'Dea F, Kent G, Stone E. A comparison of nonionic, low-osmolality radiocontrast agents with ionic, high-osmolality agents during cardiac catheterization. N Engl J Med 1992; 326:431-6. [PMID: 1732770 DOI: 10.1056/nejm199202133260702] [Citation(s) in RCA: 105] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Nonionic, low-osmolality radiocontrast agents are used frequently because they are believed to be safer than ionic, high-osmolality agents, but they are also more expensive. We conducted a randomized trial to compare the incidence of adverse events after the administration of ionic, high-osmolality and of non-ionic, low-osmolality radiocontrast agents during cardiac angiography. METHODS We compared the need to treat patients for adverse reactions and the frequency and severity of specific hemodynamic, systemic, and symptomatic side effects in two groups of patients randomly assigned to receive either ionic, high-osmolality or nonionic, low-osmolality radiocontrast material, and also in 366 patients who could not be randomized. RESULTS Treatment for adverse events was required in 213 of 737 patients who received high-osmolality contrast agents (29 percent) but in only 69 of 753 patients who received nonionic agents (9 percent) (95 percent confidence interval for the percent difference, 15.9 to 23.6 percent). Hemodynamic deterioration and symptoms also occurred more often in the high-osmolality group, as did severe or prolonged reactions (2.9 percent, as compared with 0.8 percent in the nonionic group; P = 0.035). The severe reactions were largely confined to patients with severe cardiac disease. Multivariate analysis showed that the presence of severe coronary disease and unstable angina were predictors of clinically important adverse reactions. If all the patients in our randomized trial had been given nonionic contrast material, the incremental cost per procedure would have been $89. CONCLUSIONS Nonionic, low-osmolality contrast material is better tolerated during cardiac angiography than ionic, high-osmolality contrast material. Since cost constraints may prevent the universal use of nonionic contrast material, its selective use in patients with severe cardiac disease could be considered.
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Affiliation(s)
- B J Barrett
- Department of Medicine, General Hospital, Memorial University, St. John's, Newfoundland, Canada
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14
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Steinberg EP, Moore RD, Powe NR, Gopalan R, Davidoff AJ, Litt M, Graziano S, Brinker JA. Safety and cost effectiveness of high-osmolality as compared with low-osmolality contrast material in patients undergoing cardiac angiography. N Engl J Med 1992; 326:425-30. [PMID: 1732769 DOI: 10.1056/nejm199202133260701] [Citation(s) in RCA: 95] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND METHODS Low-osmolality contrast agents produce fewer hemodynamic and electrophysiologic alterations during cardiac angiography, but they are 20 times more expensive than high-osmolality contrast agents. In a randomized, double-blind trial comparing a nonionic low-osmolality contrast agent (Omnipaque 350) with a high-osmolality agent that does not avidly bind calcium (Hypaque 76) in 505 patients undergoing cardiac angiography, we determined the incidence of minor, mild, moderate, and severe adverse reactions, identified risk factors for such reactions, and evaluated the cost effectiveness of various strategies for the use of contrast material. RESULTS The 253 patients who received a high-osmolality contrast agent were three times more likely to have a moderate adverse reaction (95 percent confidence interval for the relative risk, 1.6 to 5.5) but no more likely to have a severe reaction (95 percent confidence interval, 0.2 to 2.3) than the 252 patients who received a low-osmolality agent. All 10 severe reactions occurred in patients who were older than 60 years or had unstable angina. Patients with these characteristics were also 3.5 times more likely (95 percent confidence interval, 1.8 to 6.8) to have a moderate reaction (44 of 310 patients, or 14 percent) than those without either characteristic (8 of 195 patients, or 4 percent). We estimated that the incremental cost of each moderate reaction avoided would be $1,698 with a strategy that involved giving a low-osmolality contrast agent only to patients who were over 60 years of age or had unstable angina, instead of giving a high-osmolality agent to all patients. The incremental cost per moderate reaction avoided by giving a low-osmolality contrast agent to all patients rather than only to those over 60 or with unstable angina would be $5,842. CONCLUSIONS The use of contrast agents with low rather than high osmolality during cardiac angiography reduces the risk of moderate, but not of severe, adverse reactions to the agent used. A strategy of reserving low-osmolality contrast agents for use in patients at high risk for adverse reactions would be more cost effective than one requiring their use in all patients.
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Affiliation(s)
- E P Steinberg
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD
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Spinler SA, Goldfarb S. Nephrotoxicity of contrast media following cardiac angiography: pathogenesis, clinical course, and preventive measures, including the role of low-osmolality contrast media. Ann Pharmacother 1992; 26:56-64. [PMID: 1606346 DOI: 10.1177/106002809202600113] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To review the incidence, definition, clinical course, risk factors, pathogenesis and prevention of contrast-associated nephropathy (CAN) following cardiac angiography with emphasis on differences between high-osmolality contrast media (HOCM) and low-osmolality contrast media (LOCM). DATA SOURCES Investigations in animal models and in patients following cardiac angiography. DATA EXTRACTION Animal models of the pathogenesis of CAN are presented. Human studies describing the incidence, clinical course, risk factors, and prevention of CAN are reviewed. Comparative clinical trials of HOCM (diatrizoate, metrizoate) and LOCM (iohexol, iopamidol, ioxaglate) nephrotoxicity following cardiac angiography are critically evaluated. DATA SYNTHESIS All clinical studies comparing CAN of HOCM versus LOCM following cardiac angiography have some methodologic limitations (e.g., small sample size, lack of control for other factors) that may affect renal function, lack of stratification for other reported risk factors, and variable or short follow-up periods. CONCLUSIONS Whether the incidence of CAN following cardiac angiography is reduced with LOCM remains controversial. The incidence of CAN in patients with normal renal function does not appear to differ in patients treated with LOCM versus HOCM because few patients in each group develop renal failure. Additional controlled clinical trials comparing CAN of LOCM and HOCM in patients with renal dysfunction are needed. Because of greater product cost and scarcity of documented benefit compared with HOCM, selection of LOCM based on the presence of renal dysfunction cannot be recommended at this time.
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Affiliation(s)
- S A Spinler
- Philadelphia College of Pharmacy and Science, PA 19104
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Kern MJ. Selection of radiocontrast media in cardiac catheterization: comparative physiology and clinical effects of nonionic monomeric and ionic dimeric formulations. Am Heart J 1991; 122:195-201. [PMID: 2063737 DOI: 10.1016/0002-8703(91)90777-f] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- M J Kern
- Cardiac Catheterization Laboratory, St. Louis University Hospital, MO 63110-0250
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Matthai WH, Hirshfeld JW. Choice of contrast agents for cardiac angiography: review and recommendations based on clinically important distinctions. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1991; 22:278-89. [PMID: 2032273 DOI: 10.1002/ccd.1810220406] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Low osmolal contrast agents (LOCA) are measurably superior to high osmolal contrast agents (HOCA) in a number of properties. However, LOCA are substantially more expensive than HOCA, and universal use of LOCA for cardiac angiography would strain the health care budget. Therefore, the choice to use LOCA in place of HOCA should be based on clinically important differences. Review of available published data suggests that HOCA can be used safely and effectively for cardiac angiography in patients with mild or moderately severe heart disease. When HOCA are used, those that do not bind calcium should be chosen as they cause fewer clinically important adverse reactions than those that do bind calcium. Use of LOCA may offer added safety in high risk patients, although to date, this conclusion has not been proved with clinical experience. Nonionic LOCA may be safer to use than ionic LOCA.
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Affiliation(s)
- W H Matthai
- Cardiac Catheterization Laboratory, Hospital of the University of Pennsylvania, Philadelphia 19104
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Kotlewski A, Kawanishi D, Rahimtoola SH. Management of valvular heart disease: an illustrative cases approach. Curr Probl Cardiol 1991; 16:1-88. [PMID: 2015774 DOI: 10.1016/0146-2806(91)90003-s] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
As indicated by the 22 illustrative cases included in this monograph, a stepwise approach to the assessment of valvular heart disease provides the information necessary to make good clinical decisions. The ECG and chest x-ray add useful information to the history and physical examination. Echocardiography, Doppler, and color flow Doppler techniques have an important role in defining the presence and severity of valvular stenosis and regurgitation. Nuclear techniques provide useful information about global biventricular systolic function, regional wall motion, and myocardial perfusion. Exercise testing is most valuable in confirming objectively the patient's functional status and exercise tolerance. Newer imaging techniques, such as cine CT and MRI, are capable of displaying and measuring cardiac chamber size and myocardial thickness; however, visualization of the cardiac valves and demonstration of flow abnormalities are difficult, limiting the current usefulness of these techniques in patients with valvular heart disease.
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Affiliation(s)
- A Kotlewski
- Department of Medicine LAC/USC Medical Center
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19
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Feldman RL. A comparison of heparinized low osmolality ionic and nonionic contrast media in 500 patients undergoing cardiac angiography. Clin Cardiol 1990; 13:794-6. [PMID: 2272136 DOI: 10.1002/clc.4960131109] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Low osmolar contrast media (CM) cause less hemodynamic and electrical changes than conventional CM, and many cardiologist have switched to the newer agents. Recently, concerns about a possible increased frequency of thromboembolic complications with low osmolar CM have been raised. This study compared two low osmolar heparinized CM, one ionic (Hexabrix) and the other nonionic (Isovue), in 500 consecutive patients undergoing either diagnostic catheterization (417) or coronary angioplasty (83). Adverse effects were uncommon (37 patients), but were more frequent with Hexabrix (12%) than Isovue (3%); p less than 0.05. The most common adverse effects were nausea or vomiting. Death, related to abrupt occlusion of a severe left main stenosis occurred in one patient who received Hexabrix, and acute pulmonary edema occurred in one patient who received Isovue. No apparent thromboembolic complication occurred. In conclusion, both low osmolar CM were well tolerated, but Hexabrix caused more transient nausea or vomiting. Both CM were safe and the incidence of thromboembolic complications when prospectively looked for was very low.
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Abstract
The evolution of contrast material for intravascular use has been directed toward the development of better-tolerated agents. Currently, a variety of such "dyes" are available for coronary angiography and left ventriculography. Considerable animal and human investigation suggests that significant differences exist between the families of contrast agents that relate to patient tolerance. The newer low osmolality agents (especially the nonionic agents) produce less perturbation of the homeostatic state, which is clinically manifested by a lessened incidence of side effects, including those of a hemodynamic and electrophysiologic nature. While controversy continues over the cost/benefit ratio of the low osmolality contrast agents compared to traditional high osmolality agents, the former are rapidly becoming the community standard for diagnostic and especially therapeutic cardiologic procedures. Accepting the advantages of the low osmolality contrast agents, differences between the ionic dimers and the nonionic agents have been examined. Both experimental and clinical data suggest superiority of the nonionic agents. Although controversy still surrounds the issue of thromboembolism with the nonionic agents, accumulating evidence fails to support a clinically significant relation. The choice of contrast material is the responsibility of the invasive cardiologist. While the benefits of low osmolality agents are most obvious in high-risk patients, experience with large-scale intravenous studies suggests that the choice of contrast agent is a better discriminator of adverse reaction than is preprocedural risk stratification.
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Affiliation(s)
- J A Brinker
- Cardiac Catheterization Laboratory, Johns Hopkins Hospital, Baltimore, Maryland 21205
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Hlatky MA, Morris KG, Pieper KS, Davidson CJ, Schwab SJ, Bashore TM. Randomized comparison of the cost and effectiveness of iopamidol and diatrizoate as contrast agents for cardiac angiography. J Am Coll Cardiol 1990; 16:871-7. [PMID: 2120310 DOI: 10.1016/s0735-1097(10)80335-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
To evaluate the effectiveness and cost of low osmolarity, nonionic contrast agents for cardiac angiography, 443 patients were randomized to receive either iopamidol or diatrizoate. All adverse events that occurred within 24 h of the procedure were recorded prospectively by study personnel and classified according to previously determined criteria. Major events were defined as life threatening or requiring a procedure to treat, or both. Costs of the catheterization procedure, pharmacy, hospital laboratory and treatment of adverse events were determined on the basis of actual resource use. A total of 20 patients (8.5%) had major and 143 (61%) had minor adverse events with diatrizoate use; 10 patients (4.8%) had major and 53 (25%) had minor adverse events with iopamidol (p = 0.12 for major events; p less than 0.001 for total events). Most adverse events were treated fairly easily and inexpensively. The median overall cost was $186 higher for patients after iopamidol use compared with diatrizoate (p less than 0.0001), but all costs except the cost of the contrast agent were not significantly different between the two groups. Thus, patients who received iopamidol for cardiac angiography had a significantly lower rate of adverse events than those who received diatrizoate, but this difference was achieved at a considerably high overall cost.
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Affiliation(s)
- M A Hlatky
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
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