Do You Need Another Heart Catheterization After Last Year's Procedure?

Do I need to undergo another cardiac catheterization this year if I had one last year?

Hello Dr.
Lee,
I have been a dialysis patient for over a year and have hypertension, hyperlipidemia, and diabetes, along with coronary artery disease and mild arrhythmia.
Recently, in the past month, I experienced two episodes of hypotension during dialysis, accompanied by symptoms such as cold sweats, vomiting, and near-fainting.
While these episodes are generally considered normal, both times my heart rate also dropped significantly.
The first time it fell to 41 beats per minute, and the second time it dropped even lower to 28 beats per minute.
However, after stopping dialysis and resting, my heart rate returned to normal.
Over the past year, I have had several instances of hypotension but had never experienced a drop in heart rate until these two recent episodes.
I am currently taking Concor, which typically keeps my heart rate low, around 50 to 60 beats per minute at rest.
After the first drop in heart rate, I discontinued Concor, but the second episode still occurred, with an even lower heart rate.
My main concern is the drop in heart rate, as my doctor mentioned that hypotension usually does not lead to bradycardia.
The nurses I consulted also stated they had not seen such a situation before, which led to a referral to a cardiologist.
Last week, after undergoing myocardial perfusion imaging, the cardiologist recommended a cardiac catheterization, noting that there was 12% ischemia during the first test and 16% during the second.
Due to the bradycardia, they suspect right coronary artery stenosis.
However, there is a complication.
The hospital where I receive dialysis and the one where I see the cardiologist are different facilities.
The dialysis center suggested a cardiac catheterization.
When I returned for a follow-up appointment, the cardiologist who was supposed to perform the procedure reviewed the myocardial perfusion results and stated that the situation was not as concerning as initially thought.
After reviewing the angiography images from last October, he noted that my right coronary artery is in the best condition among my vessels, while the other two arteries are also relatively stable, with the most significant stenosis being only 50%.
Generally, it is unlikely for a vessel to progress to severe stenosis within just one year.
Therefore, his conclusion was to continue monitoring.
While the dialysis team is adjusting my treatment due to the hypotension, my primary fear is not the hypotension itself but the bradycardia.
I would like to ask the doctor whether the drop in heart rate indicates that the hypotension is caused by vascular issues.
The cardiologist at the dialysis center suggested that it could be possible to experience a myocardial infarction during dialysis or that cardiac issues could arise requiring emergency intervention.
My fear of the decreasing heart rate has made me extremely anxious about continuing dialysis.
Currently, I am undergoing dialysis at a lower speed, which may not be effective in cleansing my blood.

So, I would like to know if the episodes of hypotension accompanied by bradycardia are indeed due to vascular stenosis.
I am unclear whether the hypotension is causing the bradycardia or if the bradycardia is a result of the hypotension, as the dialysis physician mentioned they had never encountered this situation before.
Given that I had a cardiac catheterization just last October, do I really need to undergo another one?
Attached is the report from the cardiac catheterization performed last October:
Indication: (Stress Test) TL-201 (SPECT)
Pre-Cath Diagnosis: Chronic CAD
Post-Cath Diagnosis: 1VD-CAD
Intervention: No
Complication: No
Stent: No
Procedure Time: (Start 17:02 Close 17:14 Mins 12)
Contrast: Visipaque: 35 ml
Vascular Access: Artery, Trans-radial (R’t)
Intervention Methods: Additional Procedure: None
Hemodynamic: AsAo 130-/70 mmHg
Coronary Angiography:
- Dominant (R’t)
- LM - normal
- LAD - 50% stenosis, mid-LAD
- LCX - 40% stenosis
- RCA - Insignificant stenosis
- Ramus -
- Collateral -
- SYNTAX score -
Others (Selective Angiography):
Intervention Procedure:
Recommendation: Medical treatment including risk factor modification.

Gao Xiansheng, 40~49 year old female. Ask Date: 2023/12/13

Dr. Li Han reply Cardiology

Hello, regarding your inquiry, "In the past half month, I experienced two episodes of blood pressure drops during dialysis, accompanied by symptoms such as cold sweats, vomiting, and nearly fainting.
While this could be considered a common occurrence, both times my heart rate also dropped significantly.
The first time it dropped to 41 bpm, and the second time it even fell to 28 bpm.
However, after stopping dialysis and resting, my condition returned to normal.
Over the past year, I have experienced several instances of blood pressure drops, but I have never had a drop in heart rate until these two recent episodes."
During these events, there was a drop in blood pressure and significant bradycardia.
Clinically, the likelihood of a vasovagal reflex causing this is quite high, but ischemic changes cannot be completely ruled out, especially in cases of ischemia affecting the right coronary artery branches to the sinoatrial or atrioventricular nodes, although I personally believe this possibility is relatively low.
To assess this possibility, a tilt table test could be considered.
Although last year's catheterization did not reveal significant obstructive lesions, it still relies on the personal evaluation and judgment of the attending physician.
It would be advisable to discuss your concerns thoroughly with your primary physician.
The Changhua Hospital of the Ministry of Health and Welfare is concerned about your well-being.

Reply Date: 2023/12/13

More Info

Based on your detailed medical history and the findings from your recent myocardial perfusion imaging (MPI) and previous catheterization, it is understandable that you are concerned about your heart health, especially given your history of chronic kidney disease, hypertension, and coronary artery disease (CAD).

Need for Another Heart Catheterization
The decision to undergo another heart catheterization (also known as coronary angiography) should be based on several factors, including your current symptoms, the results of your recent tests, and the overall assessment of your heart condition by your healthcare providers.
1. Current Symptoms: You mentioned experiencing significant drops in your heart rate during dialysis, with episodes where your heart rate fell to dangerously low levels (41 bpm and 28 bpm). This is concerning, especially since you also experienced symptoms like cold sweats and near fainting. These symptoms could indicate a potential cardiac issue that warrants further investigation.
2. Previous Catheterization Results: Your last catheterization showed that your right coronary artery was in good condition, with only mild stenosis in the left anterior descending artery (50%) and left circumflex artery (40%). The fact that your cardiologist noted that it is uncommon for significant stenosis to develop within a year after a catheterization is reassuring. However, the presence of ischemia noted in your MPI results (12% and 16%) raises concerns about the adequacy of blood flow to the heart muscle, particularly during stress.

3. Consultation with Specialists: It is crucial to have a thorough discussion with both your nephrologist and cardiologist. The nephrologist's input is vital because your dialysis treatment can significantly affect your cardiovascular status. The cardiologist's evaluation is essential to determine if the ischemia observed in the MPI is related to the coronary artery disease or if it could be due to other factors, such as the effects of dialysis on your heart.

Relationship Between Blood Pressure Drops and Heart Rate
The relationship between your blood pressure drops and heart rate is complex. Generally, a drop in blood pressure can lead to a compensatory increase in heart rate; however, in your case, the opposite seems to be occurring. This could be due to several reasons:
- Autonomic Nervous System Response: The autonomic nervous system regulates heart rate and blood pressure. If your blood pressure drops significantly, your body usually compensates by increasing heart rate. However, if there is an underlying cardiac issue, this compensatory mechanism may not function properly, leading to bradycardia (low heart rate) instead.

- Possible Ischemia: The episodes of low heart rate during dialysis could indicate that your heart is not receiving enough blood flow, especially if the coronary arteries are narrowed. This could lead to a situation where the heart muscle is not able to maintain an adequate rate in response to stress or low blood pressure.

Recommendations
1. Further Evaluation: Given your symptoms and the findings from your MPI, it would be prudent to discuss the possibility of another heart catheterization with your cardiologist. This procedure could provide a clearer picture of your coronary arteries and help determine if there are any significant changes since your last catheterization.

2. Monitoring and Management: Continue to monitor your symptoms closely. If you experience further episodes of low heart rate or significant drops in blood pressure, seek immediate medical attention. It may also be beneficial to adjust your dialysis settings under the guidance of your nephrologist to minimize cardiovascular stress.

3. Lifestyle Modifications: Engage in lifestyle modifications that can help manage your cardiovascular risk factors, including dietary changes, regular physical activity (as tolerated), and adherence to prescribed medications.

4. Follow-Up: Regular follow-up appointments with both your nephrologist and cardiologist are essential to ensure that your condition is being monitored and managed appropriately.

In conclusion, while your previous catheterization results are reassuring, the new symptoms and MPI findings suggest that further evaluation may be necessary. Open communication with your healthcare team is key to managing your health effectively.

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