Adverse reactions of low osmolality contrast media during cardiac angiography: a prospective randomized multicenter study

Safety and tolerability of iobitridol in cerebral angiography: a prospective, multicenter study

Background

To date, only a few data have demonstrated the safety of iodinated contrast media for cerebral angiography.

Purpose

To assess contrast-related adverse events after cerebral angiography using iobitridol.

Material and Methods

A total of 790 patients who underwent cerebral angiography at three tertiary hospitals in the Republic of Korea between November 2017 and October 2018 were prospectively enrolled in this study. We interviewed all patients and recorded their symptoms before they left the interventional clinic after the angiography procedure and during the seven-day follow-up visit. The primary endpoints were acute (within 1 h) and delayed (1 h–7 days) adverse events associated with iobitridol injection. We also visually graded the radiographic density and image quality as secondary endpoints.

Results

Acute adverse events were more common than delayed adverse events. Most adverse events were either mild (96.5%) or moderate (3.45%). Among the contrast-related adverse events, feeling of warmth (59.1%) and altered taste (17.5%) were the most common acute events, whereas headache (41.9%) and allergic skin reactions (20.0%) were the most common delayed events. All cerebral angiography showed optimal density and good/excellent image quality.

Conclusion

The findings of this study suggest that iobitridol is a safe and effective iodinated contrast medium for use in cerebral angiography.

Addition of Sodium to Iohexol

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.

Iodixanol in Cardioangiography

Iodixanol (Visipaque) 320 mg I/ml, a non-ionic, dimeric, isotonic contrast medium, was compared to ioxaglate (Hexabrix) 320 mg I/ml in cardioangiography. One hundred and two patients with normal renal function were included in the study. The objectives were to evaluate safety, tolerability, radiographic efficacy and effects on renal function. Adverse events, discomfort, vital signs, clinical chemistry parameters, diagnostic information and radiographic density were recorded. Both contrast media had minor effects on the renal function parameters monitored. The patients who received iodixanol experienced fewer adverse events, significantly less discomfort and had a lower increase in heart rate than did the patients in the ioxaglate group. The radiographic efficacy was good in both groups. Iodixanol 320 mg I/ml is safe and effective for use in cardioangiography.

Tender Endothelium Syndrome: Combination of Hypotension, Bradycardia, Contrast Induced Chest Pain, and Microvascular Angina

Hypotension, bradycardia, and contrast induced chest pain are potential complications of cardiac catheterization and coronary angiography. Catheter-induced coronary spasm has been occasionally demonstrated, but its relationship to spontaneous coronary spasm is unclear. We describe a 64-year-old female who underwent coronary artery bypass surgery in 1998 on the basis of an angiographic diagnosis of severe left main disease, who recently presented with increasingly frequent typical angina. Repeat coronary angiography was immediately complicated by severe chest pain, hypotension, and bradycardia but demonstrated only mild disease of the left main artery and entire coronary tree with complete occlusion of her prior grafts. This reaction was almost identical to that observed during her original coronary angiogram. We now believe her original angiogram was complicated by severe catheter-induced left main spasm, with the accompanying contrast reaction attributed to left main disease, and the occlusion of coronary grafts explained by the absence of significant left main disease. The combination of these symptoms has not been documented in the literature. In this instance, these manifestations erroneously led to coronary bypass surgery. It is unknown whether routine, systematic injection of intracoronary nitroglycerin prior to angiography might blunt the severity of such reactions.

[Contrast media and percutaneous coronary interventions]

Contrast media are widely used for percutaneous coronary interventions. Currently, about a dozen types of contrast media are available in France. On account of their overall safety, only low osmolar and isosmolar contrast media are used in practice. However, the appropriate use of contrast media remains difficult as accurate recommendations are lacking. Several doubts are still present regarding potential adverse effects of contrast media. Our review summarizes contrast media-related risks (hypersensitivity, arrhythmic risk, effects on coagulation and platelets, contrast media-induced nephrotoxicity) underlying mechanisms, prophylaxis strategies, and differences among contrast media. Many questions remain in this area and we need further prospective randomised trials.

Adverse Reactions of Low Osmolar Non-Ionic and Ionic Contrast Media When Used Together or Separately During Percutaneous Coronary Intervention

BACKGROUND

Due to perceived advantages in the use of non-ionic contrast agents for diagnostic angiography and ionic agents for percutaneous coronary intervention (PCI), patients often receive various combinations of both types of agents.

AIM

To assess potential adverse effects of non-ionic and ionic contrast media when used together or separately during percutaneous coronary intervention.

METHODS

We retrospectively evaluated the outcomes of 532 patients undergoing percutaneous coronary intervention in our institution. Patients were divided into two groups: those that underwent diagnostic angiography and "follow on" PCI; and those that underwent "planned" PCI. The groups were subdivided on the basis of the use of the ionic agent ioxaglate or the non-ionic agent iopromide during PCI. The frequency of allergic reactions and major adverse cardiac events (MACE) were noted.

RESULTS

With respect to the "follow on" group, allergic reactions occurred in 9 of 150 patients (6.0%) who received the combination of ioxaglate and iopromide versus 1 of 93 (1.1%) who only received iopromide (p=0.094). There was no difference with respect to MACE [6 (4.0%) ioxaglate and iopromide versus 4 (4.3%) iopromide alone, p=1.00]. In the "planned" group, 7 of 165 patients (4.2%) receiving ioxaglate had an allergic reaction as opposed 0.0% (0 of 124 patients) in the iopromide group (p=0.021). All contrast reactions were mild. The incidence of a MACE was similar in both groups [1 (0.6%) ioxaglate versus 2 (1.6%) iopromide, p=0.579]. The incidence of allergic reactions was similar if ioxaglate was used alone or in combination with iopromide (p=0.478).

CONCLUSIONS

Whilst combining ionic and non-ionic contrast agents in the same procedure was not associated with any more adverse reactions than using an ionic contrast agent alone, the ionic contrast agent ioxaglate was associated with the majority of allergic reactions. With respect to choice of contrast agent, using the non-ionic agent iopromide alone for coronary intervention is associated with the lowest risk of an adverse event.

Comparative tolerability of contrast media used for coronary interventions

Radiographic contrast media (CM) are necessary to provide x-ray absorption of the bloodstream; all other observed effects need to be regarded as adverse. Four types of CM are currently used in diagnostic and interventional cardiology: ionic high-osmolar CM (HOCM), either ionic or non-ionic low-osmolar CM (LOCM), and non-ionic iso-osmolar CM (IOCM). Focusing on the potential cardiovascular effects caused by the CM, there is a clear difference between HOCM and the LOCM or IOCM. HOCM have a poorer profile due to a higher incidence of hypotension and electrophysiological effects. To prevent contrast-induced nephropathy, HOCM should be avoided and patients should receive the minimal dose of LOCM or IOCM with intravenous hydration before and after the procedure. Clinical hyperthyroidism has been detected after CM use, but the condition appears, ultimately, to be self-limited and to occur mainly in elderly patients. When assessing the need for a CM in terms of improved patient safety, preventing serious complications should be the major factor determining the choice. CM should not be selected on the basis of minor adverse effects since these are, ultimately, of low clinical relevance. Thrombotic events, in contrast, carry a high clinical relevance and we consider that these should be the main issue governing current choice. Ionic LOCM appear to have better profile than other CM with respect to interaction with platelet function and coagulation. In relation to thrombotic events in randomised clinical studies, ionic CM have been associated, mainly, with favourable and some neutral results compared with non-ionic agents. Only one trial indicated a more pronounced antithrombotic effect of the non-ionic IOCM relative to the ionic LOCM. The antithrombotic advantages of ionic over non-ionic LOCM are, in part, balanced by a greater frequency of minor adverse effects such as nausea, vomiting or cutaneous rashes. A matter of concern is the delayed adverse effects observed with non-ionic IOCM. However, severe and life-threatening reactions are exceptional and there are probably no significant differences between IOCM and LOCM whether ionic or non-ionic. However, in patients with known allergies, non-ionic CM are to be recommended. On the basis of the available pre-clinical and clinical data, the ionic LOCM or the non-ionic IOCM are the agents to be recommended in percutaneous coronary interventions because of their antithrombotic advantages over non-ionic LOCM.

Duplex ultrasound-guided femoropopliteal angioplasty: initial and 12-month results from a case controlled study

PURPOSE

To evaluate initial technical success, procedural complications, and 12-month patency of duplex-guided angioplasty compared to conventional fluoroscopically-guided procedures.

METHODS

One hundred four patients (65 men; mean age 69 years) who underwent duplex-guided femoropopliteal angioplasty were compared to 104 patients undergoing fluoroscopically-guide procedures who were matched for age, sex, baseline ankle-brachial index (ABI), and length and grade of lesion. Patients were followed for 12 months, and restenosis was assessed by ABI and duplex sonography.

RESULTS

Technical success was achieved in 88 (84.6%) patients from the duplex-guided group and in 102 (98.1%) control patients (p=0.001). Periprocedural complications occurred in 12.5% (n=13) and 18.3% (n=19), respectively (p=0.4). Contrast-induced transient renal impairment was observed in 7 (6.7%) patients in the fluoroscopic group. One hundred (96.1%) patients in the duplex and 102 (98.1%) patients in the fluoroscopic group completed the 12-month follow-up. Restenosis was found in 35 (39.8%) patients of the duplex group and in 38 (37.2%) patients of the fluoroscopic group (p=0.8).

CONCLUSIONS

Technical success of duplex-guided procedures was significantly lower compared to fluoroscopic angioplasty; complications and 12-month patency were similar with both techniques. Duplex-guided angioplasty may be a feasible alternative, particularly for patients at high risk for contrast-induced complications.

Early and late reactions after the use of iopamidol 340, ioxaglate 320, and iodixanol 320 in cardiac catheterization

BACKGROUND

Although modern contrast agents have tolerability superior to older agents, significant differences remain between the agents currently in use.

METHODS

To investigate the incidence of early (<24 hours) and late (>24 hours to 7 days) reactions to 3 contrast agents commonly used in cardiac catheterization, we performed a randomized, prospective, double-blind trial in which 2001 patients received one of the following agents: iopamidol 340, a nonionic monomer; ioxaglate 320, an ionic dimer; and iodixanol 320, a nonionic dimer. Possible reactions to contrast were recorded during the hospital admission and after discharge by means of a questionnaire, telephone follow-up, or both.

RESULTS

Early reactions occurred in 22.2% of those receiving ioxaglate, 7.6% of those receiving iodixanol, and 8.8% of those receiving iopamidol (P <.0001). Late skin reactions occurred in 12.2% of those receiving iodixanol, 4.3% of those receiving ioxaglate, and 4.2% of those receiving iopamidol (P <.0001).

CONCLUSIONS

The early side effect profile of certain ionic contrast agents suggests that these agents should no longer be used routinely in cardiac catheterization. The use of nonionic agents, however, is associated with late skin reactions, but there are notable differences between the monomeric and dimeric compounds. Although the skin reactions are generally benign, this is not always the case. Patients should be advised accordingly.

Influence of a nonionic, iso-osmolar contrast medium (iodixanol) versus an ionic, low-osmolar contrast medium (ioxaglate) on major adverse cardiac events in patients undergoing percutaneous transluminal coronary angioplasty: A multicenter, randomized, double-blind study. Visipaque in Percutaneous Transluminal Coronary Angioplasty [VIP] Trial Investigators

BACKGROUND

The potential merits and disadvantages of the use of ionic or nonionic contrast media in patients undergoing percutaneous transluminal coronary angioplasty (PTCA) have been the subjects of controversy. The present study was designed to evaluate the possible influence of both types of contrast media on major adverse cardiac events (MACE) in patients undergoing PTCA.

METHODS AND RESULTS

In a randomized, parallel-group, double-blind study, 1411 patients received either iodixanol (a nonionic, iso-osmolar contrast medium) or ioxaglate (an ionic, low-osmolar contrast medium) during PTCA. A standardized anticoagulation regimen was followed. Patients were monitored in the hospital for 2 days and followed-up at 1 month. The primary end point, a composite of MACE (death, stroke, myocardial infarction, coronary artery bypass grafting, and re-PTCA) after 2 days, occurred in 4.3% of the total population, with no statistically significant difference between groups (iodixanol, 4.7%; ioxaglate, 3.9%; P=0.45). Further, between 2-day and 1-month follow-ups, no significant difference (P=0.27) existed between the groups in the rates of MACE. Hypersensitivity reactions (P=0.007) and adverse drug reactions (P=0.002) were significantly less frequent in the iodixanol group. The only significant predicting factors for the occurrence of MACE were dissection/abrupt closure and country.

CONCLUSIONS

No significant differences were observed between the iodixanol and ioxaglate groups with regard to MACE, although hypersensitivity and adverse drug reactions were significantly less frequent in patients who received iodixanol.

Safety and criteria for selective use of low-osmolality contrast for cardiac angiography

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.

Maintenance fluids in prehospital care: crystalloid versus dextrose solutions--is there a difference?

D5W is the maintenance fluid often used in prehospital care when transporting patients with cardiac or central nervous system processes. However, there is evidence that dextrose solutions are potentially harmful, and that suggests isotonic crystalloid solutions are the preferred maintenance fluid in treating emergent patients regardless of their underlying disease. Dextrose solutions may exacerbate cellular ischemic damage and they cannot be used to resuscitate hypotensive patients. Crystalloids do not cause fluid overload when used at maintenance rates and are effective resuscitative agents in managing hypotension. The use of a single crystalloid solution in the prehospital environment would simplify equipment stocking and management protocols, minimize cost, and would not have an adverse impact on patient care.

Prevention of anaphylactoid reactions in high-risk patients receiving radiographic contrast media

OBJECTIVE

To review various pretreatment regimens for the prophylaxis of anaphylactoid reactions to radiographic contrast media (RCM) in high-risk patients. The proposed etiologies and risk factors for such reactions are also reviewed.

DATA SOURCES

A MEDLINE search of the English-language literature was used to identify pertinent human studies and reviews.

STUDY SELECTION

All studies comparing pretreatment regimens for anaphylactoid reactions to RCM were reviewed as well as studies comparing the incidence of anaphylactoid reactions between lower and higher osmolar RCM.

DATA SYNTHESIS

The two types of reactions to RCM are dose-independent, unpredictable anaphylactoid (pseudoallergic or idiosyncratic) reactions and the dose-dependent, predictable physicochemical (intrinsic, nonidiosyncratic) reactions. Prophylaxis of the former type is targeted at stemming the effects of certain chemical mediators, primarily histamine. The use of lower osmolar RCM is associated with a lower incidence of anaphylactoid reactions compared with higher osmolar RCM, but is significantly more expensive. Risk factors for such reactions are a history of previous anaphylactoid reaction to RCM, asthma, and reaction to skin allergens or penicillin. Discontinuation of any beta-blockers before the procedure is suggested. Pretesting patients with a small amount of RCM has little predictive value for an anaphylactoid reaction. Various pretreatment prophylactic regimens have been studied. Almost all included a corticosteroid to target the inflammatory response and a histamine1 (H1)-antagonist to blunt the effects of histamine. In some clinical trials, ephedrine was added for bronchodilation and cimetidine for its antagonism at the histamine2-receptor. The few controlled clinical trials that have been performed show the combination of prednisone and diphenhydramine to be most beneficial in preventing anaphylactoid reactions to RCM. The addition of ephedrine or cimetidine to a pretreatment regimen remains controversial.

CONCLUSIONS

More controlled clinical studies comparing various pretreatment regimens for high-risk patients need to be performed, especially in patients receiving lower osmolar RCM. Recommendations for high-risk patients who must receive RCM include use of a lower osmolar agent, pretreatment with a corticosteroid and an H1-antagonist, discontinuation of beta-blockers if the patient is taking any, and bedside availability of appropriate medications and equipment to treat anaphylaxis.

Comparison of a low osmolarity nonionic radiographic contrast agent with a standard medium on renal function in cyanotic and normal dogs

Renal dysfunction may follow administration of iodinated radiographic contrast agents. This complication may be less common when low osmolarity nonionic agents are used. Although potential benefits from the use of low osmolarity nonionic contrast may be minimal in individuals with normal physiology, a greater benefit has been postulated in the presence of chronic cyanosis. To test this hypothesis, six adult mongrel dogs underwent anastomosis of the inferior vena cava to the left atrium. This produced chronic cyanosis with a mean pO2 of 48 +/- 4 mm Hg and polycythemia with a mean hematocrit of 56 +/- 2 gm%. Three to 5 months after preparation, these cyanotic dogs and five control dogs each received diatrizoate (a high osmolarity ionic agent) or ioversol (a low osmolarity nonionic agent), 465 mg iodine/kg body weight, by intravenous bolus injection. One month later, each animal received the other agent. The order of administration was randomized. Renal function studies, including serum creatinine and creatinine clearance, were performed precontrast, after 60 min, and 24 hr postcontrast. Neither agent adversely affected renal function in either the cyanotic or the normal group. We conclude that at the doses that are commonly used in clinical practice, high osmolarity ionic contrast agents do not create a greater risk of renal injury than do low osmolarity nonionic agents in this model of cyanosis.

Iodixanol and ioxaglate in cardioangiography: a double-blind randomized phase III study

A new non-ionic, dimeric contrast medium iodixanol (Nycomed AS, Norway) has a very low osmolality and is isotonic with blood. It has been compared with ioxaglate (Hexabrix, Laboratoire Guerbet, France) in a double-blind, randomized, parallel trial. The aims of the trial were to evaluate and compare the safety (vital signs, adverse events, discomfort and clinical-chemical parameters in blood and urine) and radiographic efficacy (diagnostic information and radiographic density) of iodixanol 320 mg I/ml vs ioxaglate (Hexabrix 320 mg I/ml) in coronary angiography and left ventriculography. Seventy-six patients referred for cardioangiography, two patients were withdrawn, 36 receiving iodixanol and 38 ioxaglate were included in the trial. Six patients (16%) in the iodixanol group and 16 (42%) patients in the ioxaglate group reported adverse events (P = 0.02). One serious adverse event occurred in the iodixanol group where a patient experienced transient cortical blindness and transitory global amnesia, but the patient recovered completely the day after the examination. Twenty-six patients reported injection-associated sensation of warmth in the iodixanol group versus 34 in the ioxaglate group (P = 0.06). Following contrast injection there were no differences between the groups regarding vital signs (ECG, heart rate, left ventricular pressures). Both contrast media were well tolerated by the kidneys, and on average only minor effects on clinical-chemical parameters in blood and urine were observed in the two groups. The radiographic efficacy was good in both groups.

Use of nonionic or low osmolar contrast agents in cardiovascular procedures. American College of Cardiology Cardiovascular Imaging Committee

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.