Thanks to visit codestin.com
Credit goes to link.springer.com

Skip to main content

Cognitive and Decision-Making Skills in Catheter-Based Cardiovascular Interventions

  • Chapter
  • First Online:
Catheter-Based Cardiovascular Interventions
  • 3361 Accesses

  • 12 Citations

Abstract

For the past nearly four decades, performance of catheter-based cardiovascular interventions has been considered largely inaccessible to formal scrutiny. It has been assumed that interventional knowledge and skills are based on empiricism and can be transferred only tacitly. In addition, over the past decades, the importance of clinical trials based evidence and charms of instrumentation technology have been strongly overemphasized with these factors contributing to the demise of the importance of cognitive skills and decline of technical abilities of the operators, both required for the procedural interventional expertise. In this chapter, the key importance of cognitive skills for interventional expertise has been emphasized. Development of training curricula and clinical practice based on deliberate practice and acquisition of relevant cognitive skills is needed to raise the level of professional standards and to improve the quality of interventional services in the best interest of all stakeholders, of which our patients are the most important.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Subscribe and save

Springer+
from £29.99 /Month
  • Starting from 10 chapters or articles per month
  • Access and download chapters and articles from more than 300k books and 2,500 journals
  • Cancel anytime
View plans

Buy Now

Chapter
GBP 19.95
Price includes VAT (United Kingdom)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
GBP 119.50
Price includes VAT (United Kingdom)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Similar content being viewed by others

Notes

  1. 1.

    The actual increase in options is more than expressed by the exponential equation because the number of initial options increases. For example, to increase support second guide-wire, to increase back up of different guiding-catheter, etc., can be considered.

References

  1. Dotter CT, Judkins MP (1964) Transluminal treatment of arteriosclerotic obstruction. Circulation 30:654–670

    Article  PubMed  CAS  Google Scholar 

  2. Arendt H (1971) The life of the mind. Harcourt, Brace, Jovanovich, San Diego/New York/London

    Google Scholar 

  3. Gilson E (1936) The spirit of medieval philosophy. University of Notre Dame Press, Notre Dam

    Google Scholar 

  4. Kant I (2000) Critique of the power of judgment. Cambridge University Press, Cambridge

    Google Scholar 

  5. Gazzaniga MS (ed) (2005) The cognitive neurosciences III. MIT Press, Boston

    Google Scholar 

  6. Glimcher PW, Caterer CF, Fehr E, Holdback RA (2009) Neuroeconomics; decision making and the brain. Elsevier, Amsterdam/Boston/Heidelberg

    Google Scholar 

  7. Stanovich KE (1999) Who is rational? Studies of individual differences in reasoning. Erlbaum, Mahweh

    Google Scholar 

  8. Stanovich KE (2004) The robot’s rebellion: finding meaning in the age of Darwin. University of Chicago Press, Chicago

    Google Scholar 

  9. Stanovich KE, West RF (2002) Individual differences in reasoning: implications for the rationality debate. In: Gilovich T, Griffin D, Kahneman D (eds) Heuristics and biases. Cambridge University Press, Cambridge, pp 421–440

    Chapter  Google Scholar 

  10. Kahneman D (2011) Thinking, fast and slow. Pinquin Books, London, p 105

    Google Scholar 

  11. Leslie AM (1987) Pretense and representation: the origins of “theory of mind”. Psychol Rev 94:412–426

    Article  Google Scholar 

  12. Perner I (1991) Understanding the representational mind. MIT Press, Cambridge

    Google Scholar 

  13. Stanovich KE (2008) Distinguishing the reflective, algorithmic, and autonomous minds: is it time for a tri-process theory? In: Evans J, Frankisch K (eds) In two minds: dual process and beyond. Oxford University Press, Oxford

    Google Scholar 

  14. Wang Y, Wang Y, Patel S, Patel D (2006) A layered reference model of the brain (LRMB). IEEE Trans Syst Man Cybern 36:124–133

    Google Scholar 

  15. Ebbinghaus H (1885) Über das Gedächtnis. Untersuchungen zur experimentellen Psychologie. Duncker & Humblot, Leipzig

    Google Scholar 

  16. Bloom BS (ed) (1956) Taxonomy of educational objectives, the classification of educational goals handbook I: cognitive domain. McKay, New York

    Google Scholar 

  17. Ericsson KA (ed) (2009) Development of professional expertise. Cambridge University Press, Cambridge

    Google Scholar 

  18. Ericsson KA, Charness N, Feltovich PJ, Hoffman RR (eds) (2006) The Cambridge handbook of expertise and expert performance. Cambridge University Press, Cambridge

    Google Scholar 

  19. Ericsson KA, Krampe RTh, Tesch-Römer C (1993) The role of deliberate practice in the acquisition of expert performance. Psychol Rev 100:363–406

    Article  Google Scholar 

  20. Holyoak KJ, Cheng PW (2011) Causal learning and inference as a rational process: the new synthesis. Annu Rev Psychol 62:135–163

    Article  PubMed  Google Scholar 

  21. Sullivan ME, Brown CV, Peyre SE, Salim A, Martin M, Towfigh S, Grunwald T (2007) The use of cognitive task analysis to improve the learning of percutaneous tracheostomy placement. Am J Surg 193:96–99

    Article  PubMed  Google Scholar 

  22. Campbell JC (2010) Employing cognitive task analysis supported instruction to increase medical student and surgical resident performance and self-efficacy. Dissertation presented to the Faculty of the USC Rossier School of Education, University of Southern California (unpublished)

    Google Scholar 

  23. Tirapille LA (2010) The effect of cognitive task analysis based instruction on surgical skills expertise and performance. Dissertation presented to the Faculty of the USC Rossier School of Education, University of Southern California, in partial fulfillment of the requirements for the Degree of Doctor of Education (unpublished)

    Google Scholar 

  24. Maupin FG (2010) Comparing cognitive task analysis to behavior task analysis in training first year interns to place central venous catheters. Dissertation proposal presented to the Faculty of the USC Rossier School of Education, University of Southern California (unpublished)

    Google Scholar 

  25. Aristotle (1962) Categories and De Interpretatione (trans: Ackrill JH). Clarendonce Press, Oxford

    Google Scholar 

  26. Taylor R (1957) The problem of future contingencies. Philos Rev 66:1–28

    Article  Google Scholar 

  27. Taylor R (1962) Fatalism. Philos Rev 71:56–66

    Article  Google Scholar 

  28. Devin K. The unfinished game: Pascal, Fermat, and the seventeeth century letter that made the world modern. New York: Basic Books, 2008

    Google Scholar 

  29. Arnauld A, Nicole P (1996) Logic or the art of thinking. Cambridge University Press, Melbourne, pp 274–275

    Google Scholar 

  30. Bernoulli D (1954) Exposition of a new theory on the measurement of risk. Econometrica 22:23–36 (translation from Specimen theoriae novae de mensura sortis. Commentarii Academiae Scientiarum Imperialis Petropolitanae, Tomus V, 1738:175–192

    Google Scholar 

  31. Bayes T (1763) An essay toward solving a problem in the doctrine of chances. Philos Trans Essay LII:370–418

    Article  Google Scholar 

  32. von Neumann J (1928) Zur Theorie der Gesellschaftsspiele. Math Ann 100:295–320

    Article  Google Scholar 

  33. von Neumann J, Morgenstern O (1944) Theory of games and economic behavior. Princeton University Press, Princeton

    Google Scholar 

  34. Shannon CE, Weawer W (1963) The mathematical theory of communication. Chicago University Press, Urbana/Chicago; copyright 1949

    Google Scholar 

  35. Turing AM (1936) On computable numbers, with an application to the Entscheidungsproblem. Proceedings of London Mathematical Society, series 2, 42:230–265

    Google Scholar 

  36. Zadeh L (1965) Fuzzy sets. Inf Control 8:338–353

    Article  Google Scholar 

  37. Lorenz EN (1963) Deterministic non-periodic flow. J Atmos Sci 20:130–141

    Article  Google Scholar 

  38. Alexander C (1964) Notes on the synthesis of form. Harvard University Press, Cambridge

    Google Scholar 

  39. Goethe JW von (2012) Faust, Teil 1. http://www.­gutenberg.org/cache/epub/2229/pg2229.html. Accessed 19 Jan 2012

  40. Wang Y, Ruhe G (2007) The cognitive process of decision making. Int J Cognit Inf Nat Intell 1(2):73–85

    Article  Google Scholar 

  41. Peterson M (2009) An introduction to decision theory. Cambridge University Press, Cambridge

    Google Scholar 

  42. Kahneman D, Slovic P, Tversky A (eds) (1982) Judgment under uncertainty: heuristics and biases. Cambridge University Press, Cambridge

    Google Scholar 

  43. Smith JQ (2010) Bayesian decision analysis; principles and practice. Cambridge University Press, Cambridge

    Book  Google Scholar 

  44. Meehl PE (1996) Clinical versus statistical prediction: a theoretical analysis and a review of the evidence. Jason Aronson, Minnesotta

    Google Scholar 

  45. Klein G (1999) Sources of power: how people make decisions. MIT Press, Cambridge

    Google Scholar 

  46. Kahneman D, Klein G (2009) Conditions for intuitive expertise: a failure to disagree. Am Psychol 64:515–526

    Article  PubMed  Google Scholar 

  47. Arkes HR (2001) Overconfidence injudgmental forecasting. In: Armstrong JS (ed) Principles of forecasting: a handbook for researchers and practitioners. Kluwer Academic, Boston, pp 495–516

    Google Scholar 

  48. Bishop MA, Trout JD (2004) Epistemology and the psychology of human judgment. Oxford University Press, New York

    Google Scholar 

  49. List of cognitive biases. http://en.wikipedia.org/wiki/List_of_cognitive_biases. Accessed 4 Nov 2011

  50. Gigerenzer G, Gaissmaier W (2011) Heuristic decision making. Annu Rev Psychol 62:451–482

    Article  PubMed  Google Scholar 

  51. Reason J (1990) Human error. Cambridge University Press, Cambridge

    Book  Google Scholar 

  52. Kahneman D, Tversky A (1979) Prospect theory: an analysis of decision under risk. Econometrica 47:263–291

    Article  Google Scholar 

  53. Bernstein PL (1998) Against gods; remarkable story of risk. Wiley, Philadelphia

    Google Scholar 

  54. National Defence and the Canadian Forces. www.forces.gc.ca. Accessed 5 Sept 2011

  55. Ferguson N. (2008) The ascent of money. Penguin Books, London, pp 192–196

    Google Scholar 

  56. Center for Chemical Process Safety (2009) Guidelines for developing quantitative safety risk criteria. Wiley, Hoboken

    Google Scholar 

  57. Safety management system for aviation. http://www.safeopsys.com/docs/SOS_SMS_Article.pdf. Accessed 5 Sept 2011

  58. Semmelweis I (1983) The etiology, concept, and prophylaxis of childbed fever. University of Wisconsin, Wisconsin; translated from Semmelweis IP. Die Aetiologie, der Begriff und die Prophylaxis des Kindbettfiebers. Original published 1860. Reprinted from: Györy von T (ed) (2007) Semmelweis’ gesammelte Werke. In copyright: Verlag Dr. Müller, Saarbrücken

    Google Scholar 

  59. Kohn LT, Corrigan JM, Donaldson MS (eds) (Committee of Quality of Health Care in America, Institute of Medicine) To err is human: building a safer health system. (http://books.nap.edu/html/to_err_is_human/exec_summ.html)

  60. Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek PJ (2010) Temporal trends in rates of patient harm resulting from medical care. N Engl J Med 363:2124–2134

    Article  PubMed  CAS  Google Scholar 

  61. Sherman H, Loeb J (for Joint Commission on Accreditation of Healthcare Organizations, WHO Consultants) (2005) The WHO World Health Organization Alliance for patient safety. World Health Organization. http://www.who.int/patientsafety/taxonomy/IPSET_Sept05_FINAL.pdf (accessed March 18, 2012).

  62. Prechelt L, Lanzer P (2006) The decision-making process in percutaneous coronary interventions. In: Lanzer P (ed) Mastering endovascular techniques: a guide to excellence. Lippincott Williams & Wilkins, Philadelphia, pp 103–113

    Google Scholar 

  63. Lanzer P, Prechelt L (2011) Expanding the base for teaching of percutaneous coronary interventions: the explicit approach. Catheter Cardiovasc Intervent 77:372–380

    Article  Google Scholar 

  64. Lanzer P, Prechelt L (2008) Spelling out risk reduction strategies for intracoronary stenting. EuroIntervention 3:622–626

    Article  PubMed  Google Scholar 

  65. ACCF/AHA Task Force on Practice Guidelines. Manual for ACCF/AHA Guideline Writing Committees: methodologies and policies from the ACCF/AHA Task Force on Practice Guidelines. Available at http://assets.cardiosource.com/Methodology_Manual_for_ACC_AHA_Writing_Committees.pdf and http://circ.ahajournals.org/manual/. American College of Cardiology and American Heart Association. Accessed 1 Oct 2010

  66. Gawande A (2011) The checklist manifesto: how to get things right. McMillan, Philadelphia

    Google Scholar 

  67. Morrow DA, Antman EM, Charelsworth A, Cairns R, Murphy SA, de Lemos JA, Giugliano RP, McCabe CH, Braunwald E (2000) TIMI risk score for ST-elevation myocardial infarction: a convenient, bedside, clinical score for risk assessment at presentation. Circulation 102:2031–2037

    Article  PubMed  CAS  Google Scholar 

  68. Antman EM, Cohen M, Bernink PJ, McCabe CH, Horacek T, Papuchis G, Mautner B, Corbalan R, Radley DE (2000) The TIMI score for unstable angina/non-ST-elevation MI: a method for prognostication and therapeutic decision making. JAMA 284:835–842

    Article  PubMed  CAS  Google Scholar 

  69. Ranasighe I, Alprandi-Costa B, Chow V, Elliott JM, Waites J, Counsell JT, Lopez-Sendon J, Avezum A, Goodman SG, Granger CB, Brieger D (2011) Risk stratification in the setting of Non-ST elevation acute coronary syndromes 1999–2007. Am J Cardiol 108:617–624

    Article  Google Scholar 

  70. Ryan TJ, Dp F, Gunnar RM et al (1988) Guidelines for percutaneous transluminal coronary angioplasty: a report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures. J Am Coll Cardiol 12:529–545

    Article  Google Scholar 

  71. Sianos G, Morel M-A, Kappetein AP, Morice M-C, Colombo A, Dawkins K, van den Brand M, van Dyck N, Russell ME, Mohr FW, Serruys PW (2005) The SYNTAX score: an angiographic tool grading the complexity of coronary artery disease. EuroIntervention 1:219–227

    PubMed  Google Scholar 

  72. Lanzer P (2006) Coronary interventions. In: Lanzer P (ed) Mastering endovascular techniques: guide to excellence. Lippincott, Williams & Wilkins, Philadelphia, pp 208–225

    Google Scholar 

  73. KDOQI clinical practice guidelines for ghronic kidney disease: evaluation, classification, and stratification. http://www.kidney.org/professionals/kdoqi/guidelines_ckd/toc.htm (accessed March 18, 2012).

  74. Manual on contrast media v7. American College of Radiology. http://www.acr.org/SecondaryMainMenuCategories/quality_safety/contrast_manual.aspx (accessed March 18, 2012).

  75. Jones DM, Song X, Rockwood K (2004) Operationalizing a frailty index from a standardized comprehensive geriatric assessment. J Am Geriatr Soc 52:1929–1933

    Article  PubMed  Google Scholar 

  76. Lanzer P (2003) Vascular multimorbidity in patients with a documented coronary artery disease. Z Kardiol 92:650–659

    Article  PubMed  CAS  Google Scholar 

  77. Lanzer P, Weser R, Prettin C (2007) Intentional single-stage revascularization of two different vascular beds in patients with vascular multimorbidity: a feasibility study. Clin Res Cardiol 96:497–501

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Peter Lanzer M.D. .

Editor information

Editors and Affiliations

Appendixes

Appendixes

10.1.1 Appendix A – Risk Accounting in Industry: An Example

Lacking comprehensive risk control concepts in health care, the structure of a risk control program published by the Center for Chemical Process Safety (CCPS) [56] supplemented by nomenclature from aviation industry [57] shall be briefly reviewed.

Establishment of risk control programs starts with descriptive and standardized terminology of relevant hazard themes (Table 10.5). The subsequently developed safety management system (SMS) details methods to identify, analyze, and control all relevant hazards inherent to the ­enterprise; tracks risk mitigation efforts; and provides means to detect yet unexplored emerging hazards. SMS entails four components: safety policy, safety management, safety assurance, and safety promotion; each dedicated to subtasks designed to meet the overall safety goals. CCPS has outlined safety elements under four major headings:

  • Commitment to process safety containing process safety culture and competency, ­compliance with standards, workforce involvement, and stakeholder outreach

  • Understanding hazards involved in the enterprise

  • Risk management including operating ­procedures, safe work practices, integrity and reliability assets, training and assurance of performance, conduct of operations, and emergency management

  • Learning from experience based on incident investigation, measurement and metrics, auditing, management review, and continuous improvement

Analysis of hazards involved in a specific process typically starts with asking questions such as “What can (what did) go wrong?” “What are the consequences?” “How likely is it to happen?” “How do consequences and frequency combine?” “Is the current level of risk tolerable, considering the existing safeguards? If not, what needs to be done to reduce and manage the risk?” Efficiency of the analytical process preferably conducted in what-if-brainstorming sessions must be assured by involving experts intimately familiar with that processes. The benefits of expert-based rational risk management cited by CCPS include:

  • Logical way to analyze risk

  • Confidence that risk management decisions are rationally determined and not arbitrarily made

  • Greater consistency in risk-based decision-making across the organization

  • Provision of basis for prioritizing/apportioning finite resources

  • Provision of protection of organization’s permission to operate

Addressing the issue of uncertainty, CCPS acknowledges limitations of the current mathematical models of physical reality to predict events and to account for all relevant risks and risk factors. It pledges for continuous refinements of models based on rational data analysis.

In proactive safety management programs, the estimates of the likelihood of incidents are based on review of historical records of similar events (retroactive analysis), design of fault and event tree diagrams, and analysis of common cause failures and factors concerning human reliability. Comprehensive analysis of all relevant individual and societal risk factors involved in a given operation should inform the stakeholders about the rates of equipment failures and possibilities and types of human errors. It also should adequately instruct decision makers to issue guidelines and employ other necessary risk control measures.

Table 10.5 Terminology of terms related to risk management (based on Ref. [56] and [57])

10.1.2 Appendix B – Risk Accounting in Medicine: Initial Attempts

Risk accounting in medicine has a long and distinguished tradition punctuated by some heroic battles and characterized by recent deficits.

The dictum “first, does no harm” (primum non nocere) based on a statement in the Hippocratic Corpus Volume VII: Epidemics (∼ fourth century B.C.) sums the guiding principle of risk accounting in medicine ever since. The actions of physicians should be always guided by careful weighing of the risks against the expected benefits in the best interest of their patients. An example of violation of this principle provide writings by Ignaz Philipp Semmelweis [58].

In considering the risk accounting in medicine, three fundamental aspects are important: first, the physician acts on behalf of the patient who carries the potential harm alone; second, the knowledge of risk is highly asymmetrical between the two parties; third, the risk at stake—health—is considered the highest of man’s goods.

Risk accounting in medicine appears particularly difficult due to the large number of known and unknown dynamic variables involved. Consider, for example, the risk assessment of chemotherapy in a patient with leukemia with poorly defined status of the remaining stem cells, tumor cell burden, and presence of associated diseases that is professionally exposed to X-ray radiation. No formula can assess the risk of treatment of the standard or modified course of treatment.

Formally, based on risk and benefit considerations, four basic categories of treatment outcomes can be distinguished (Table 10.6); however, in clinical practice, transitions between treatment outcomes are far more complex and fluent. The first step of risk control in medicine is risk ­awareness, closely followed by risk prevention. In a bold move in 1999, the Institute of Medicine, Washington, DC, has launched a major initiative to improve patients’ safety in health care [59]. Their main focus was to standardize terminology (Table 10.7), to promote safe practices, and to assure transparency in handling of errors in health care. In their introduction, the authors remarkably stated:

Yet silence surrounds this issue (of errors). For the most part, consumers believe they are protected. Media coverage has been limited to reporting ­anecdotal cases. Licensure and accreditation confer, in the eyes of the public, a “Good Housekeeping Seal of Approval”. …. Yet, licensing and accreditation process have focused only limited attention on the issue, even these minimal efforts have confronted some resistance from health care organizations and providers.  ….. The goal of this report is to break this cycle of inaction….. The focus must shift from blaming individuals for past errors to a focus on prevention future errors by designing safety into the system….. Health care is a decade or more behind other high-risk industries in its attention to ensuring basic safety.

Have their goals been met? Recent report based on evaluation of risk control measures evaluated in selected participating hospitals 10 years after launching the initiative says no [60]; not much has changed. A similar initiative has been launched by the World Health Organization (WHO) [61]. The main focus of this initiative has been to standardize terminology of errors (Table 10.8) and to propose guidelines for their control. The impact of this initiative in medical communities has not yet been established.

Table 10.6 Basic treatment outcomes in terms of risk and benefit evaluations
Table 10.7 Selected useful terms applicable to hazards and adverse events in medicine [59]
Table 10.8 Examples of errors recognized in medicine [61]

10.1.3 Appendix C (Table 10.910.14)

Table 10.9 TIMI NSTEMI score (Ref. [67])
Table 10.10 TIMI STEMI score (Ref. [68])
Table 10.11 GRACE score (Ref. [69])
Table 10.12 ACC/AHA coronary artery lesion classification (Ref. [70])
Table 10.13 SYNTAX score; weighting factors (Ref. [71])
Table 10.14 SYNTAX score; Lesions adverse characteristics (Ref. [71])

10.1.4 Appendix D (Based on Ref. [72])

10.1.4.1 Latent Risk: Patient Factors

The latent risk associated with CBCVI is partly related to the patients’ overall state of health, emphasizing specific organ functions, presence of diabetes, allergic disposition, old age fragility, and panvascular status.

10.1.4.1.1 Heart Function and Coronary Status

Impaired left ventricular (LV) function, particularly if associated with the right ventricular (RV) dysfunction, increases the latent risk of CBCVI, particularly in cardiac interventions. The latent risk is proportional to the severity of dysfunction. Based on the echocardiography measurements of the left ventricular ejection fraction (LVEF), mild, LVEF  >  45%, moderate, LVEF >30%, and severe, LVEF  <  30%, reduction of the systolic left ventricular function can be distinguished. In patients with a chronic but stable mild-to-moderate impairment, adequate avoidance of volume overload and hypertension usually suffice to ­control the heart failure. In patients, with acute cardiac failure or severe chronic ventricular dysfunction, additional pharmacological or mechanical support might be required.

In jeopardy score, the impact of the LV dysfunction on procedural risk has been defined; one point has been assigned for each myocardial segment supplied by the target vessel or by vessels with a diameter stenosis ≥70% and half-point was assigned to myocardial segments that were hypokinetic and were not supplied by a vessel with a significant stenosis. Jeopardy score calculation is based on a simplified AHA/ACC coronary segment classification (Table 10.15).

Table 10.15 Jeopardy score

Patients with high jeopardy scores and patients with target vessels supplying the majority of viable myocardium, ejection fraction < 20-30% or patients with cardiogenic shock or critical multiple vessel coronary artery disease have been considered candidates for supported PCI. Besides the severity, the cause and the duration of the LV dysfunction should also be considered. Acutely ischemic myocardium lacking the protective collateral vascularization appears to represent a greater risk compared to similar LV dysfunction due to established ischemia.

10.1.4.1.2 Renal Function

Cardiovascular interventions guided by X-ray angiography and fluoroscopy are associated with contrast agent exposure ranging from 50 up to 500 ml/procedure (main range 70–200 ml/procedure), depending on the kind of the intervention. X-ray contrast agents are not metabolized and are excreted exclusively via the kidney in a chemically unchanged state. Their administration is one of the most common causes of progression of renal dysfunction in patients with chronic kidney disease along with other states such as volume depletion, use of specific antibiotics (e.g., aminoglycosides), nonsteroidal anti-inflammatory agents, angiotensin-converting-enzyme inhibitors, cyclosporin, and urinary tract obstructions.

It is important to realize that in healthy individuals, the renal excretory function decreases with age (Table 10.16).

Table 10.16 Glomerular filtration rate as a function of age in men and women (Ref. [73])

To reduce the risk of procedure-related deterioration of the renal function or occurrence of renal failure, the interventionalists should know the baseline renal function or the stage of the chronic renal disease, if present. Stages of chronic kidney disease are based on functional impairment determined by glomerular filtration rate: chronic kidney disease is defined either as kidney damage or GFR  <  60 ml/min/1.73 m2 for ≥3 months. Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies (From Ref. [73]) (Table 10.17, 10.18).

Table 10.17 Stages of renal insufficiency based on ­glomerular filtration rate Ref. [73]
Table 10.18 The prevalence of stage 3 chronic renal failure reaches up to 25% in ≥70 years old patients

Contrast-induced nephropathy (CIN) has been defined as ≥25% increase in serum creatinine from baseline or absolute increase by 44.2 μmol/l (0.5 mg/dl) within 48 h after application of a contrast agent lasting for a minimum of 2 days. Patients at risk for developing CIN include those with preexisting renal disease, type II diabetes regardless of age, elderly, aged, and dehydrated patients, patients on nephrotoxic medication, and those with a prolonged hypotension, high contrast media exposure, (>200 ml), repeated contrast media exposures, or those with application of high osmolarity agents. Measures to prevent are reviewed in Table 10.19:

Table 10.19 Prevention of contrast agent-induced nephropathy modified from Gleeson TG et al. Brit J Cardiol 2004;11:53-61

To mitigate risk of CIN in patients with high risk, the admission rules include:

  • Hospitalization 2 days prior to PCI

  • Adequate hydration and judicious use of diuretics!

  • Staging diagnostic coronary angiography and PCI by >10 days

  • Avoiding other procedures requiring contrast agents

  • Using biplane angiography, if available

  • Consideration of preventive hemodialysis in high-risk patients with high contrast exposure.

In patients developing CIN despite preventive measures, the severity and progression of renal dysfunction must be closely monitored. Management of patients with established CIN includes:

  • Transfer to intensive care unit where acute hemodialysis is available

  • Close monitoring of input and output

  • Daily determination of creatinine, urea, and electrolytes for 5 days as needed

  • Consultations with nephrologists as needed

Table 10.20 Treatment of metabolic derangements associated with contrast agent-induced nephropathy (CIN) is reviewed

Installing the preventive measures shall reduce the incidence of CIN in a vast majority of patients including in those with stage IV chronic renal failure. In patients with chronic renal insufficiency, besides considering the risk of CIN, the high incidence of extensive vascular calcifications requires consideration in planning the intervention Table 10.20.

10.1.4.1.3 Patients with Thyroid Disease

Application of iodinated contrast agents during CBCVI is associated with a high iodine exposure. However, although ∼15–100 g of iodine, corresponding to 1,500–10,000-fold amount of total iodine content of the human body, is applied, only a fraction of this amount, approximately 0.1–0.001‰ (0.5–36 ig/ml), is biologically active-free inorganic iodine. In addition, some free iodine is generated by deiodination of the organically bound iodine (∼0.1–0.2‰ of the total administered dose within 1 h of exposure). The free iodine may, however, induce thyrotoxicosis in susceptible patients such as those with hyperthyroid disease, immunologically based thyroid disease, autonomic thyroid tissue, multinodular goiter in individuals living in endemic iodide-deficient regions, and in patients receiving certain medications (e.g., amiodarone, expectorans) or those having particular nutritional habits (e.g., kelp ingestion).

Iodide-induced thyrotoxicosis (IIT) is frequently associated with sustained adverse cardiovascular effects including cardiac arrhythmias, conduction abnormalities, and heart failure. Life-threatening symptoms of persistent heart failure and threatening arrhythmias may occur in compromised patients. To reduce the risk of IIT, screening is required prior to CBCVI. The checklist typically includes the assessment of the history of thyroid disease, exclusion of offensive medication, palpation of the thyroid gland, and laboratory examinations (thyroid stimulating hormone (TSH)) assay is performed; if suppressed (decreased), free triiodothyronine (T3) and, less frequently, free tetraiodothyronine (fT4) are measured.

Preventive measures prior to CBCVI are recommended in patients at risk for IIT. Extended drug treatment is mandatory in patients at risk, and in those with overt thyrotoxicosis scheduled for emergency, CBCVI are reviewed in the Table 10.21.

Table 10.21 Prevention of hyperthyroidosis in patients on risk

In stable patients with overt hyperthyroidosis, CBCVI should be deferred until the thyroid function has been normalized. The attendance to the precautionary measures and preventive treatments has markedly reduced the incidence of ITT to the point when it has become a rarity.

10.1.4.1.4 Diabetes Mellitus

Presence of diabetes and diabetic angiopathy is associated with greater latent risk and poorer outcome of CBCVI. For example, in patients with a clinically relevant coronary artery disease (CAD), the incidence of the left main lesions and multivessel, diffuse disease, large plaque burden, and poor collateralization is significantly higher compared to the nondiabetic patients with CAD. Despite the marked improvements in interventional treatments and significant reduction of procedure-related complications, the incidence of clinical endpoints such as short-term and long-term mortality, target lesion and target vessel revascularization, thrombotic occlusion, and restenosis has remained significantly higher in diabetics compared to nondiabetics in both elective and emergency settings.

To reduce the latent risk related to the altered metabolic state and differences in diabetic angiopathy in diabetic patients undergoing CBCVI, a number of diabetes-specific issues and patient-related factors need to be considered, including greater underestimation of the severity and extent of the vascular, but particularly the CAD compared to nondiabetics, greater ­likelihood of vascular and organ multi-morbidity, metabolic instability, greater likelihood of contrast ­agent-induced nephropathy, greater potential of side effects from medications, especially biguanides, and greater likelihood of immune incompetence and infection. To avoid metabolic complications, tight metabolic control and adjustments in medication, if required, are reviewed in the Table 10.22.

Table 10.22 Peri-interventional monitoring of patients with diabetes

In addition to the metabolic state of the diabetic patients, the peculiarities of the diabetic vasculopathy need to be considered. Long lesions, diffuse character of the disease, and greater ­propensity for extensive calcifications should be accounted in designing the strategy and in ­performing the interventions. Plaque modification, selection of particular non-traumatizing instrumentation, long stents, etc., are some of the measures potentially applicable.

10.1.4.1.5 Allergy

The increase in the latent risk in patients with known allergies or allergic predisposition is relatively low. Adverse responses to iodine contrast agents (ICA) occur in ∼5–10% of patients undergoing CBCVI with very mild reactions occurring in the majority of cases. Moderate-to-severe adverse responses have been estimated at 1–2‰ and fatalities at ∼0.001‰ (0.0003–0.0026‰) of ICA applications. The use of nonionic low-osmolality contrast agents has been considered safer and represents the current choice in the majority of patients. Allergy-like and true allergy responses are possibly more common in patients with a history of asthma and allergies to medications, food, and metals. In predisposed patients, the symptoms are not only more frequent but tend to be also more severe.

Although the exact mechanism of adverse responses to ICA has not been elucidated in the literature, non-anaphylactoid (chemotoxic, vasovagal, and idiopathic) and anaphylactoid (idiosyncratic “allergy-like” and true allergic) responses are distinguished. Non-anaphylactoid chemotoxic responses may be dose dependent and include primarily nephrotoxic and neurotoxic, as well as some cardiovascular effects (e.g., arrhythmogenicity). Anaphylactoid responses may be nonspecific reactions due to as yet unknown mediators, or they may be mediated by antibodies (IgE) or T-lymphocytes. Nearly all severe responses occur within minutes (≤20 min) following ICA exposure. In rare cases, late responses (up to 7 and more days), consisting usually of mild urticaria, bronchospasm, or renal dysfunction, have been reported.

Prophylactic medication is recommended for all predisposed patients and for those with previous adverse responses to ICA. The suggested oral regimen consists of:

  • Prednisone 50 mg p.o., 12, 6, and 1 h prior to exposure

  • Diphenhydramine, H1-antihistamine, 50 mg p.o., 12 and 1 h prior to exposure

  • Ranitidine, H2-histamine receptor blocker, 50 mg p.o., 1 h prior to exposure

An intravenous regimen can alternatively be given in patients unable to take oral medication.

In patients experiencing allergy-like responses following the exposure to ICA, the treatment depends on the type and the severity of symptoms. The majority of responses are grade 1, very mild symptoms, consisting of urticaria, pruritus, and diaphoresis without systemic symptoms. Grade 2 is associated with mild-to-moderate dyspnea due to laryngeal edema and bronchospasm, hypo­tension due to vasodilatation, and abdo­minal symptoms (nausea, vomiting, abdominal pain). In grade 3, moderate-to-severe dyspnea and profound hypotension occur. Grade 4 refers to severe cardiocirculatory and pulmonary compromise and/or arrest Table 10.23.

Table 10.23 Allergy, treatment recommendations (Ref. [74])
Table 10.1 Classification of cognitive processes in the layered reference model of the brain (LRMB)
Table 10.2 Example of representative choices of criteria employed by decision makers [40]
Table 10.3 Basic error types and their characteristics
Table 10.4 Summary of some of the main features and causes of the main error types

It is important to achieve the full relief of symptoms and to restore a stable cardiocirculatory and pulmonary function prior to resuming the intervention.

10.1.4.1.6 Fragile Patients

The majority of patients undergoing CBCVI are 60–80 years old, yet the proportion of the aged (>80 years) is increasing. Fragility and advanced age have been acknowledged as markers for a more advanced and more severe vascular disease and higher incidence of comorbidities.

In patients with no overt or active disease, the estimation of frailty accounting for factors such as general health status, medication intake, nutritional state, weight, mobility, coordination, strength, self-sufficiency, cognition, affectivity, and social interaction based on metrics such as frailty index [75] may be useful to determine the appropriateness of CBCVI and considerations regarding surgery. In high-risk interventions, life quality gained and life expectations should be also considered.

In patients suffering from a relevant or limiting nonvascular and/or concomitant vascular disease, the latent risk may exceed the expected benefits, and thorough weighting of pros and cons of CBCVI is required. If CBCVI has been indicated, special precautions are required including implementations of the least traumatic therapy option, short procedure time, close post-procedural monitoring, and early hospital discharge. Following CBCVI, polypharmacy should be avoided. When prescribing anticoagulants and antithrombotic agents, the increased risk of bleeding should be considered.

10.1.4.1.7 Panvascular Patients

Panvascular disease has been defined as clinically significant vascular disease in at least two major vascular territories. The major risk factors for panvascular state are type II diabetes regardless of age and the age <75 years [76]. In panvascular patients, likely both the latent and the actional risk are increased. To mitigate the actional risk, the operator should take into account the entire vascular morbidity of the patient; in addition to the standard protocols, the relevance of the disease of all involved vascular beds must be evaluated often requiring interdisciplinary expertise. If several procedures are required, their order is based on urgency and cumulative procedural risk. Frequently, in patients with clinically relevant CAD, the coronary interventions are performed first. However, simultaneous interventions in two different vascular territories and hybrid procedures in the same or different vascular beds may also represent valid options (Ref. [77]).

10.1.4.1.8 Critically and Terminally Ill Patients

Critically and terminally ill patients with an assumed life expectancy ≤6 months are eligible for palliative CBCVI in all emergency cases. In these patients, both the latent and the actional risk are likely increased. Although, palliative interventions are always indicated, futile interventions are not. The indications for elective procedures in critically and terminally ill patients are based on the assessment of the actional risk-to-expected-benefit ratio. In these patients, the gain in quality of life represents the lead target of the intervention. However, in all cases, the wish of the patient and ethical considerations shall override the assessed ratios.

10.1.4.2 Lesion Factors

Lesion factors relevant to risk can be broadly divided into those associated with the vasculature, proximal to the target site, and those associated with the target site.

10.1.4.2.1 Access Vasculature

The vessels between the access site and the target site may be hostile to catheter-based cardiovascular interventions due to elongation, excessive tortuosity, anomalies, aneurysms, high plaque burden, multiplicity of lesions, etc. Although the presence of a single or several of these factors may remain clinically silent and latent risk neutral, the actional risk may go up, depending on the degree of traumatization. The puncture of highly calcified vessels, the use of larger or longer sheaths, the deployment of stiff guide-wires or extra long guides increase actional risk due to the increased incidence of bleedings, vessel wall injury, or even perforation. The presence of diffuse disease, multiple plaques, and high calcification of the access vasculature increases the risk destabilization of silent plaques, distal embolization, dissections, or other types of traumatization. The magnitude of the added actional risk due to the presence of these factors relates to severity of these changes on one hand and the facility of the technique employed. Highly skilled approach may significantly reduce or even eliminate the added actional risk with the less-skilled approach causing just the opposite.

10.1.4.2.2 Target Site

The hostile target sites are those associated with increased actional risk in proportion to their complexity. Depending on morphological findings, the increase in risk can be additive, multiplicative, or even exponential. Target site morphologies associated with increased actional risk have been reviewed elsewhere [64]. The operator’s actions may mitigate or aggravate the expected actional risk.

Rights and permissions

Reprints and permissions

Copyright information

© 2013 Springer-Verlag Berlin Heidelberg

About this chapter

Cite this chapter

Lanzer, P. (2013). Cognitive and Decision-Making Skills in Catheter-Based Cardiovascular Interventions. In: Lanzer, P. (eds) Catheter-Based Cardiovascular Interventions. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-27676-7_10

Download citation

  • DOI: https://doi.org/10.1007/978-3-642-27676-7_10

  • Published:

  • Publisher Name: Springer, Berlin, Heidelberg

  • Print ISBN: 978-3-642-27675-0

  • Online ISBN: 978-3-642-27676-7

  • eBook Packages: MedicineMedicine (R0)

Keywords

These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Publish with us

Policies and ethics