This document outlines guidelines for post-catheterization follow up to monitor patients for changes in their condition and prepare them for discharge. Key aspects of monitoring include checking haemodynamics, symptoms of ischemia or heart failure, arrhythmias, and contrast-induced nephropathy. Potential complications are discussed like bleeding, access site issues, and allergic reactions. The document also covers instructing patients on activity levels, follow up care including medication and lifestyle changes, and timing of return to work.

1. Post Catheterization Follow Up
Chairperson: Prof Dr. Syed Ali Ahsan
Dr. Md. Fysal Faruq
Resident Phase B
Yellow unit

2. Aims of Follow up
• Monitoring for changes in haemodynamics
• Monitoring for new symptoms
• Monitoring for contrast induced nephropathy
• Prepare the patient for ambulation
• Prepare the patient for discharge

3. Change of haemodynamics
• Possible causes:
• Blood loss
• Myocardial ischaemia
• Heart failure
• Arrhythmia
• Hypovolemia due to inadequate pre-hydration

4. Haemodynamics monitoring in CCU
• After PCI patient should be monitored in a
cardiac ward that has facility of continuous
ECG monitoring and nurses expertized with
routine post-PCI care.
• Check vital signs every 15 minutes for the first
2 hours then every hourly
• Pulse, BP, Urine output, Precordium, Lungs,
peripheral pulses, puncture site

5. Monitoring for myocardial ischaemia
• A 12-lead ECG should be obtained just after
PCI to find out any new changes
• Measurement of Troponin I or CK(MB)
-Symptoms of ischaemia
-New ECG changes

6. Monitoring for contrast-induced
nephropathy
• Ensure first voiding of urine
• Encourage oral fluid intake
• Nephrotoxic drugs should be withheld 24
hours before and 48 hours after procedure
• Post-procedure oral or saline hydration should
be continued to maintain urine output >
30ml/hour
• Renal function should be monitored in
patients with DM and renal dysfunction.

7. Monitoring for Heart failure
• Correlate with symptoms and signs: SOB,
Palpitation, tachycardia, bilateral basal creps
• Arrangement for immediate bed-side
echocardiography should be available
- New wall motion abnormalities
- Development of Pericardial effusion or
temponade

8. Monitoring for Arrhythmias
• Any type of arrhythmias are possible
• Common: sinus tachycardia, sinus bradycardia,
• Life threatening: AF, VT, VF
• Arrangement for pharmacological and DC
cardioversion Should be available

9. Access site management
• Sheath removal:
• Trans-femoral access
Manual compression
Vascular closure device
• Trans-radial access
Manual compression
Wristband compression device(TR band)

10. Timing of sheath removal(SCAI)
• Trans-femoral access
 Heparin used as anticoagulant
ACT falls below 175 seconds
 Bivalirudin used as anticoagulant
o Creatinine Clearance >30ml/hour
2 hours after discontinuation of bivalirudin
o CCR <30ml/hour or haemodialysis
ACT falls below 175 seconds

11. • Trans-radial access
Immediate sheath removal regardless of
anticoagulant status
Patent haemostasis technique

12. Ambulation
• Trans-femoral access
Manual compression: 2-6 hours
Vascular closure device: 1-4 hours
• Trans-radial access
May ambulate as soon as sheath removal
Avoid weight bearing or other activity for 2-4
hours

13. Physician patient communication
• The results of the procedure, including any
complications, unexpected findings, should be
explained clearly to the patient and his or her
family.
• The type of intervention, if any, and the
duration of dual antiplatelet therapy (DAPT)
should also be discussed and reinforced
repeatedly by the team of care providers
throughout the duration of the patient stay.

14. Instructions after sheath removal
• Keep the punctured limb straight and do not
flex knee for 6 hours
• During coughing or sneezing, apply pressure
to puncture site
• Should not strain or lift anything >5pound
(2.25kg) within 48hours
• Call the duty nurse or doctor if oozing from
puncture site, painful swelling, neurological
symptoms like tingling, numbness, parasthesia

15. Blood loss
• Possible causes:
• Haematoma
• Retroperitoneal haemorrhage
• Puncture site bleeding

16. Haematoma
• Collection of blood under the skin in soft
tissues directly as a result of arterial/venous
injury
• Pain
• Firm swelling around access site
• Red or purple skin discoloration
• Tachycardia, hypotension

17. • Treatment:
• Manual compression to prevent further
enlargement of hematoma
• Mark the boundaries of the hematoma to
monitor growth and effectiveness of
compression
• Blood grouping, crossmatching, Blood
transfusion if needed
• Vascular surgery consultation

18. Retroperitoneal Haemorrhage
• Suprainguinal tenderness
• Back pain
• Lower quadrant abdominal pain
• Grey Turner’s sign
• Hypotension, tachycardia
• Confirmation: Abdominal CT

19. • Treatment:
• Can be treated by supportive care
(transfusions, close observation, and bed rest)
in > 80% of cases
• Anticoagulation should be reversed
• Frequent hemodynamic monitoring in an
experienced intensive care unit
• If the bleeding does not spontaneously stop,
then vascular surgery consultation

20. Other complicatios

21. Pseudoaneurysms
• Dilation of an artery with actual disruption of one
or more layers of its wall
• Pulsatile mass over puncture site
• Auscultation: Systolic bruit
• Confirmation: Ultrasound
• Treatment:
• Less than 2 cm: Often close spontaneously
• 2-3 cm: USG guided compression(90%success)
• More than 3 cm: Surgical correction

22. Arteriovenous fistula
• Formation of a direct communication between
an artery and a vein
• Auscultation: Continuous murmur
• Confirmation: Ultrasound
• Treatment:
• Usually small and no consequence
• USG guided compression/Surgical closure if:
Significant shunt
Extreme swelling and tenderness
CHF, DVT

23. Acute arterial occlusion
• Pulselessness
• Pain
• Pallor
• Paresthesias
• Cool extremities

24. • Treatment:
• Angiography of affected extremity with access
from another extremity
• Dissection requires stenting or surgery
• Thromboembolism can be treated with
surgical(Fogarty catheter) or percutaneous
mechanical thrombectomy (Possis angiojet)

25. Allergic reaction
• Shivering
• Fever
• Shortness of breath
• Treatment:
• Inj. Hydrocortisone
• Inj. Chlorpheniramine
• Inj. Adrenaline

26. Vasovagal Syncope
• Lightheadedness
• Nausea, vomiting, sweating
• Bradycardia
• Hypotension
• Treatment:
• Intravenous fluid
• Inj. Atropine
• Inj. Adrenaline

27. Prepare patient for next step
Discharge

28. Discharge instructions
• Physical activity after the procedure
• Dietary and Lifestyle advice
• Need for additional laboratory testing
afterwards
• Follow up

29. Activity Level
• Should refrain from physical exercise for 48
hours after procedure
• Should refrain from driving for 48 hours after
procedure
• Should refrain from sexual activity for 1 week
after procedure to allow access site healing
• AHA consensus statement: sexual activity is
reasonable for patients at low risk for
cardiovascular complications and for those who
can exercise for 3 to 5 METs without symptoms
or ECG changes

30. Dietary and lifestyle advice
• Heart healthy diet ( fruits, vegetables, whole
grain, low fat dairy products, skinless poultry
and fish, nuts and legumes, non tropical
vegetable oil)
• Weight reduction in obese
• Avoid smoking, alcohol
• Increased physical activity
• Limit saturated fat, trans fat, extra salt, red
meat, sweets and sugar-sweetened beverages

31. Return to work
• Decision to return to work is individualized
Type of work the patient performs
Physical demands
Mental stress
Safety considerations
Job satisfaction
Employer policies

33. Follow UP
• Timing: 2-4 weeks after the procedure
Sooner for patients with
- Procedural complications
- Anaemia
- Renal dysfunction

34. Purpose of follow-up visit
• To ensure compliance with the medication
regimen, especially with regard to DAPT
• To reinforce aggressive secondary prevention
measures, including dietary and exercise
habits and smoking cessation
• To confirm that the patient has enrolled in a
cardiac rehabilitation programme

35. Post PCI medication
• Continue DAPT as per guideline
• Continue other medication as appropriate
• If indication for oral anticoagulant
-Start NOAC the next day
-Start warfarin immediately with a F/U
PT(INR) within 1 week
• If renal impairment Metformin should be
started after renal function returns to normal

38. Thank You