1
|
Miner SES, McCarthy MC, Ardern CI, Perry CGR, Toleva O, Nield LE, Manlhiot C, Cantor WJ. The relationships between acetylcholine-induced chest pain, objective measures of coronary vascular function and symptom status. Front Cardiovasc Med 2023; 10:1217731. [PMID: 37719976 PMCID: PMC10501450 DOI: 10.3389/fcvm.2023.1217731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/31/2023] [Indexed: 09/19/2023] Open
Abstract
Background Acetylcholine-induced chest pain is routinely measured during the assessment of microvascular function. Aims The aim was to determine the relationships between acetylcholine-induced chest pain and both symptom burden and objective measures of vascular function. Methods In patients with angina but no obstructive coronary artery disease, invasive studies determined the presence or absence of chest pain during both acetylcholine and adenosine infusion. Thermodilution-derived coronary blood flow (CBF) and index of microvascular resistance (IMR) was determined at rest and during both acetylcholine and adenosine infusion. Patients with epicardial spasm (>90%) were excluded; vasoconstriction between 20% and 90% was considered endothelial dysfunction. Results Eighty-seven patients met the inclusion criteria. Of these 52 patients (60%) experienced chest pain during acetylcholine while 35 (40%) did not. Those with acetylcholine-induced chest pain demonstrated: (1) Increased CBF at rest (1.6 ± 0.7 vs. 1.2 ± 0.4, p = 0.004) (2) Decreased IMR with acetylcholine (acetylcholine-IMR = 29.7 ± 16.3 vs. 40.4 ± 17.1, p = 0.004), (3) Equivalent IMR following adenosine (Adenosine-IMR: 21.1 ± 10.7 vs. 21.8 ± 8.2, p = 0.76), (4) Increased adenosine-induced chest pain (40/52 = 77% vs. 7/35 = 20%, p < 0.0001), (5) Increased chest pain during exercise testing (30/46 = 63% vs. 4/29 = 12%, p < 0.00001) with no differences in exercise duration or electrocardiographic changes, and (6) Increased prevalence of epicardial endothelial dysfunction (33/52 = 63% vs. 14/35 = 40%, p = 0.03). Conclusions After excluding epicardial spasm, acetylcholine-induced chest pain is associated with increased pain during exercise and adenosine infusion, increased coronary blood flow at rest, decreased microvascular resistance in response to acetylcholine and increased prevalence of epicardial endothelial dysfunction. These findings raise questions about the mechanisms underlying acetylcholine-induced chest pain.
Collapse
Affiliation(s)
- Steven E. S. Miner
- Division of Cardiology, Southlake Regional Health Centre, Newmarket, ON, Canada
- School of Kinesiology and Health Science, Muscle Health Research Centre, York University, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Mary C. McCarthy
- Division of Cardiology, Southlake Regional Health Centre, Newmarket, ON, Canada
| | - Chris I. Ardern
- School of Kinesiology and Health Science, Muscle Health Research Centre, York University, Toronto, ON, Canada
| | - Chris G. R. Perry
- School of Kinesiology and Health Science, Muscle Health Research Centre, York University, Toronto, ON, Canada
| | - Olga Toleva
- Department of Cardiology, Emory University, Atlanta, GA, United States
| | - Lynne E. Nield
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Cedric Manlhiot
- The Blalock-Taussig-Thomas Pediatric and Congenital Heart Center, Department of Pediatrics, Johns Hopkins University, Baltimore, MD, United States
| | - Warren J. Cantor
- Division of Cardiology, Southlake Regional Health Centre, Newmarket, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
2
|
Mahtta D, Jain A, Elgendy IY. Acute adverse drug reactions with contrast media after cardiac catheterization: can we identify those at risk? J Thorac Dis 2019; 11:2669-2671. [PMID: 31463089 PMCID: PMC6687994 DOI: 10.21037/jtd.2019.06.47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 06/17/2019] [Indexed: 08/29/2023]
Affiliation(s)
- Dhruv Mahtta
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Ankur Jain
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Islam Y Elgendy
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville, FL, USA
| |
Collapse
|
3
|
Goberdhan S, Chiew SK, Syed J. Tender Endothelium Syndrome: Combination of Hypotension, Bradycardia, Contrast Induced Chest Pain, and Microvascular Angina. Case Rep Cardiol 2016; 2016:8574025. [PMID: 26981290 PMCID: PMC4769742 DOI: 10.1155/2016/8574025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 01/14/2016] [Accepted: 01/17/2016] [Indexed: 11/17/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Shivesh Goberdhan
- Department of Internal Medicine, Queens University, Kingston General Hospital, 76 Stuart Street, Kingston, ON, Canada K7L 2V7
| | - Soon Kwang Chiew
- Department of Cardiology, McMaster University, St. Catharines Hospital, 1200 4th Avenue, St. Catharines, ON, Canada L2S 0A9
| | - Jaffer Syed
- Department of Cardiology, McMaster University, St. Catharines Hospital, 1200 4th Avenue, St. Catharines, ON, Canada L2S 0A9
| |
Collapse
|
4
|
Acute kidney injury after transcatheter aortic valve implantation: Impact of contrast agents, predictive factors, and prognostic importance in 203 patients with long-term follow-up. J Cardiol 2015; 66:514-9. [DOI: 10.1016/j.jjcc.2015.02.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 01/31/2015] [Accepted: 02/19/2015] [Indexed: 01/29/2023]
|
5
|
Honoris L, Zhong Y, Chu E, Rosenthal D, Li D, Lam F, Budoff MJ. Comparison of contrast enhancement, image quality and tolerability in Coronary CT angiography using 4 contrast agents: A prospective randomized trial. Int J Cardiol 2015; 186:126-8. [PMID: 25818754 DOI: 10.1016/j.ijcard.2015.03.240] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Accepted: 03/17/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Lily Honoris
- 1124W Carson St, Torrance, CA 90502, United States
| | - Yan Zhong
- 1124W Carson St, Torrance, CA 90502, United States
| | - Edwin Chu
- 1124W Carson St, Torrance, CA 90502, United States
| | | | - Dong Li
- 1124W Carson St, Torrance, CA 90502, United States
| | - Franklin Lam
- 1124W Carson St, Torrance, CA 90502, United States
| | | |
Collapse
|
6
|
Tadrous M, Gagne JJ, Stürmer T, Cadarette SM. Disease risk score as a confounder summary method: systematic review and recommendations. Pharmacoepidemiol Drug Saf 2013; 22:122-9. [PMID: 23172692 PMCID: PMC3691557 DOI: 10.1002/pds.3377] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2012] [Revised: 10/20/2012] [Accepted: 10/23/2012] [Indexed: 01/16/2023]
Abstract
PURPOSE To systematically examine trends and applications of the disease risk score (DRS) as a confounder summary method. METHODS We completed a systematic search of MEDLINE and Web of Science® to identify all English language articles that applied DRS methods. We tabulated the number of publications by year and type (empirical application, methodological contribution, or review paper) and summarized methods used in empirical applications overall and by publication year (<2000, ≥2000). RESULTS Of 714 unique articles identified, 97 examined DRS methods and 86 were empirical applications. We observed a bimodal distribution in the number of publications over time, with a peak 1979-1980, and resurgence since 2000. The majority of applications with methodological detail derived DRS using logistic regression (47%), used DRS as a categorical variable in regression (93%), and applied DRS in a non-experimental cohort (47%) or case-control (42%) study. Few studies examined effect modification by outcome risk (23%). CONCLUSION Use of DRS methods has increased yet remains low. Comparative effectiveness research may benefit from more DRS applications, particularly to examine effect modification by outcome risk. Standardized terminology may facilitate identification, application, and comprehension of DRS methods. More research is needed to support the application of DRS methods, particularly in case-control studies.
Collapse
Affiliation(s)
- Mina Tadrous
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto
ON
| | - Joshua J. Gagne
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of
Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston MA
| | - Til Stürmer
- Department of Epidemiology, UNC Gillings School of Global Public
Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | |
Collapse
|
7
|
Tavakol M, Ashraf S, Brener SJ. Risks and complications of coronary angiography: a comprehensive review. Glob J Health Sci 2012; 4:65-93. [PMID: 22980117 PMCID: PMC4777042 DOI: 10.5539/gjhs.v4n1p65] [Citation(s) in RCA: 99] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Accepted: 12/29/2011] [Indexed: 12/17/2022] Open
Abstract
Coronary angiography and heart catheterization are invaluable tests for the detection and quantification of coronary artery disease, identification of valvular and other structural abnormalities, and measurement of hemodynamic parameters. The risks and complications associated with these procedures relate to the patient’s concomitant conditions and to the skill and judgment of the operator. In this review, we examine in detail the major complications associated with invasive cardiac procedures and provide the reader with a comprehensive bibliography for advanced reading.
Collapse
|
8
|
Flinck A, Gottfridsson B. Experiences with iohexol and iodixanol during cardioangiography in an unselected patient population. Int J Cardiol 2001; 80:143-51. [PMID: 11578707 DOI: 10.1016/s0167-5273(01)00460-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
AIM To compare the frequency of adverse events after cardioangiography with iohexol and iodixanol in an unselected patient population with special regard to previously defined "risk patients": age> or =65 years, severe coronary artery disease, unstable angina pectoris and left ventricular dysfunction. METHODS A total of 1020 patients referred to cardioangiography were included in this open, prospective cross-sectional study, comparing iodixanol (320 mgI/ml) and iohexol (350 mgI/ml). Adverse events were recorded and the patients answered a questionnaire. RESULTS Cardiac adverse events (CAE) i.e., angina pectoris, arrhythmia and dyspnea within 24 h of examination were reported by 9% of patients receiving iohexol and by 7% receiving iodixanol. Two cases of ventricular fibrillation occurred, both after iohexol. The proportion of CAE was 11% for patients> or =65 years receiving iohexol and 7% in younger patients. For patients receiving iodixanol the proportion was 7%, in both age groups. Patients with severe coronary disease had more CAE than less ill patients in both CM groups. The proportion of unstable patients with CAE was 18% in the iohexol group and 12% in the iodixanol group. Left ventricular dysfunction was not related to CAE. CONCLUSIONS Iodixanol could be advantageous in patients with unstable angina.
Collapse
Affiliation(s)
- A Flinck
- Department of Radiology, Göteborg University, Sahlgrenska University Hospital, SE 413 45 Göteborg, Sweden.
| | | |
Collapse
|
9
|
Bergstra A, van Dijk RB, Brekke O, Buurma AE, Orozco L, den Heijer P, Crijns HJ. Hemodynamic effects of iodixanol and iohexol during ventriculography in patients with compromised left ventricular function. Catheter Cardiovasc Interv 2000; 50:314-21. [PMID: 10878628 DOI: 10.1002/1522-726x(200007)50:3<314::aid-ccd9>3.0.co;2-d] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
A crossover study was performed to compare the hemodynamic effects of the iso-osmolar contrast agent iodixanol (Visipaque) 320 mg I/ml to those of the low-osmolar iohexol (Omnipaque) 350 mg I/ml. The main hypothesis was that iodixanol and iohexol would affect left ventricular end-diastolic pressure (LVEDP) to different degrees. In 48 patients with reduced cardiac function (mean ejection fraction 33. 4%), one ventricular injection was performed with each contrast medium. Ventricular, aortic and right atrial pressures and heart rate were measured continuously. Cardiac output (using Fick's principle) and systemic vascular resistance were calculated. LVEDP increased with both agents, but significantly less after iodixanol than after iohexol (P < 0.01), also in subgroups of patients in whom baseline LVEDP was severely increased and in whom 3-vessel disease was present. Immediate changes in variables reflecting vasodilatation were similar with both agents. In conclusion, both contrast agents influenced hemodynamics during ventriculography, but iodixanol had significantly less influence on LVEDP than did iohexol.
Collapse
Affiliation(s)
- A Bergstra
- Department of Cardiology/Thoraxcenter, Groningen University Hospital, The Netherlands.
| | | | | | | | | | | | | |
Collapse
|
10
|
Scanlon PJ, Faxon DP, Audet AM, Carabello B, Dehmer GJ, Eagle KA, Legako RD, Leon DF, Murray JA, Nissen SE, Pepine CJ, Watson RM, Ritchie JL, Gibbons RJ, Cheitlin MD, Gardner TJ, Garson A, Russell RO, Ryan TJ, Smith SC. ACC/AHA guidelines for coronary angiography. A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on Coronary Angiography). Developed in collaboration with the Society for Cardiac Angiography and Interventions. J Am Coll Cardiol 1999; 33:1756-824. [PMID: 10334456 DOI: 10.1016/s0735-1097(99)00126-6] [Citation(s) in RCA: 659] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
|
11
|
Randolph AG, Guyatt GH, Calvin JE, Doig G, Richardson WS. Understanding articles describing clinical prediction tools. Evidence Based Medicine in Critical Care Group. Crit Care Med 1998; 26:1603-12. [PMID: 9751601 DOI: 10.1097/00003246-199809000-00036] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Clinical prediction rules and models are developed by applying statistical techniques to find combinations of predictors that categorize a heterogeneous group of patients into subgroups of risk. Our goal is to teach clinicians how to evaluate the validity, results, and applicability of articles describing clinical prediction tools. CLINICAL EXAMPLE: An article describing a rule to predict the need for intensive care unit care admission in patients presenting to the emergency room with chest pain. RECOMMENDATIONS Valid clinical prediction tools are developed by completely following up a representative group of patients, by evaluating all potential predictors and testing the independent contribution of each predictor variable, and by ensuring that the outcomes were independent of the predictors. To evaluate the results of an article describing a clinical prediction tool, clinicians need to know what the prediction tool is, how well it categorizes patients into different levels of risk, and what the confidence intervals are around the risk estimates. Valid prediction tools are not applicable in every patient population. Before patient care application, the clinician should ensure that the tool maintains its prediction power in a new sample of patients, that the patients are similar to patients used to test the tool, and that the tool has been shown to improve clinical decision-making. CONCLUSIONS There has been an increase in the development and validation of clinical prediction rules and models. It is important to evaluate the validity and reliability of these prediction tools before application.
Collapse
Affiliation(s)
- A G Randolph
- Department of Anesthesia and Pediatrics, Children's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | | |
Collapse
|
12
|
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.
Collapse
Affiliation(s)
- B J Barrett
- Clinical Epidemiology Unit, Memorial University of Newfoundland, St. John's.
| | | | | |
Collapse
|
13
|
Kussmaul WG, Mishra JP, Matthai WH, Hirshfeld JW. Complications of cardiac angiography using low- or high-osmolality contrast agents in patients with left main coronary stenosis. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1997; 42:376-9. [PMID: 9408613 DOI: 10.1002/(sici)1097-0304(199712)42:4<376::aid-ccd3>3.0.co;2-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Recently published guidelines suggest that, in view of cost concerns, low-osmolal contrast should be selectively used in patients at increased risk of experiencing a contrast-related complication during cardiac angiography. The suggested criteria include the presence of left main coronary disease. However, the presence of left main disease is not usually known prior to angiography. Contrast-related complications of cardiac angiography were therefore analyzed in a group of 111 clinically stable patients found to have left main coronary stenosis, to determine if use of low-osmolality contrast had any beneficial effect when compared to standard contrast. Data were gathered prospectively as part of a randomized controlled trial, and the subgroup of patients with left main disease was analyzed retrospectively. Complications were divided into minor, intermediate, and major categories. In the 58 patients who received high-osmolar contrast, there were 4 contrast-related minor reactions, 8 intermediate events requiring treatment, and 1 major adverse event. Among the 53 patients who received low-osmolar contrast, there were no minor reactions, 7 intermediate events requiring treatment, and no major adverse events. The only difference of borderline significance was in the incidence of minor reactions requiring no treatment (P = 0.05). Although small and therefore not definitive, this study suggests that 1) universal use of low-osmolar contrast agents would not be expected to eliminate the risk of contrast-related reactions to cardiac angiography; 2) the well-documented clinical differences between high- and low-osmolar contrast primarily involve mild reactions; and 3) standard high-osmolar contrast is reasonably safe in clinically stable patients with left main coronary stenosis. The results therefore are consistent with the notion that selective use of low-osmolar contrast only in unstable patients is safe and appropriate.
Collapse
Affiliation(s)
- W G Kussmaul
- Department of Medicine, Allegheny University Hospital/Hahnemann Division, Philadelphia, Pennsylvania 19102, USA
| | | | | | | |
Collapse
|
14
|
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.
Collapse
Affiliation(s)
- S Jost
- Division of Cardiology, Hannover Medical School, Germany
| | | | | | | | | |
Collapse
|
15
|
Abstract
Intravascular contrast agents have several side effects including alterations of the hemostasis and the complement system. The effects on these systems may be one of the main causes of the "adverse contrast agent reaction." In vitro and in vivo evidence is provided that both ionic and nonionic contrast media activate the plasma kallikrein with consecutive activation of the factor XII-contact phase and stimulation of the bradykinin generation. Furthermore, activation of the complement cascade via the classic and the alternative pathways was described to a various extent for intravascular application of contrast agents. In non-reactors, these alterations are transient and only have a limited extent indicating that these reactions are within the regulatory capacity of the kallikrein-kinin-factor XII system. In reactors, however, significant evidence for an extended activation of the kallikrein system is associated with reduced levels of C1-esterase inhibitor. Therefore, patients with alterations in these systems should be regarded as candidates for adverse contrast agent reactions. Furthermore, contrast media influence the blood coagulation, especially in contact to artificial surfaces (plastic or glass). In vitro findings suggest that there is a broad scope of modifications caused by contrast agents indicating a modification of the risk of thromboembolism during angiography. Preliminary data suggest that an inhibition of clot formation is more effective with ionic compared with nonionic contrast agents. In summary, radiographic contrast agents have an impact both on the hemostasis and the complement systems. The effects may be of importance for adverse reactions as well as for thromboembolic complications during angiography.
Collapse
|