Heart, Lung and Circulation
Review| Volume 29, ISSUE 2, P169-177, February 2020

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Sedation and Analgesia for Cardiac Catheterisation and Coronary Intervention

Published:September 09, 2019DOI:


      While cardiac catheterisation is typically well tolerated, discomfort and anxiety are commonplace. Sedation using anxiolytic and analgesic medications has the potential to ameliorate such symptoms, however, is variably employed, with lack of standardised regimens and limited evidence.


      We performed a review of the role of sedation for cardiac catheterisation, including current practices and summarising available evidence relevant to diagnostic and interventional coronary procedures in the cardiac catheterisation laboratory.


      Use of sedation and the medication regimens employed are highly variable. Available relevant studies are limited in number and mostly small. Sedation appears to modestly reduce anxiety and pain in most studies. The incidence of radial spasm and the consequent need to alter access site is reduced with procedural sedation. The majority of existing evidence applies to benzodiazepines and opioid use, which appear acceptably efficacious and safe when used with appropriate training and staffing; noting opioid medications reduce the absorption of loading doses of oral anti-platelet drugs.


      In conclusion, benzodiazepines and opioids result a modest reduction in pain, improved patient tolerability and reduced risk of radial artery spasm. The decision on whether to use sedation, and which agent(s) and dose, should be individualised based on patient factors, including need for oral antiplatelet therapy administration. Appropriate staffing and monitoring is essential.


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        • Bashore T.M.
        • Balter S.
        • Barac A.
        • Byrne J.G.
        • Cavendish J.J.
        • Chambers C.E.
        • et al.
        American College of Cardiology Foundation/Society for Cardiovascular Angiography and Interventions Expert Consensus Document on cardiac catheterization laboratory standards update.
        J Am Coll Cardiol. 2012; 59: 2221-2305
        • Bertrand O.F.
        • Rao S.V.
        • Pancholy S.
        • Jolly S.S.
        • Rods-Cabau J.
        • Larose É.
        • et al.
        Transradial approach for coronary angiography and interventions: results of the first international transradial practice survey.
        JACC Cardiovasc Interv. 2010; 3: 1022-1031
        • Lavi S.
        • Jolly S.S.
        • Bainbridge D.
        • Manji F.
        • Randhawa V.
        • Lavi R.
        Sedation, analgesia, and anaesthesia variability in laboratory-based cardiac procedures: an international survey.
        Can J Cardiol. 2014; 30: 627-633
        • Thomas S.P.
        • Thakkar J.
        • Kovoor P.
        • Thiagalingam A.
        • Ross D.L.
        • MacIsaac A.
        • et al.
        CSANZ position statement on sedation for cardiovascular procedures (2014).
        Heart Lung Circ. 2015; 24: 1041-1048
        • Wagenaar T.C.
        • Rohling W.J.
        • Klomp M.
        • Meesterman M.G.
        • Henriques J.P.S.
        Sedative treatment regimes in all Dutch centers carrying out percutaneous coronary interventions, a comprehensive nationwide survey.
        Eur J Cardiovasc Nurs. 2010; 9: 195-196
        • Kezerashvili A.
        • Fisher J.D.
        • DeLaney J.
        • Mushiyev S.
        • Monahan E.
        • Taylor V.
        • et al.
        Intravenous sedation for cardiac procedures can be administered safely and cost-effectively by non-anesthesia personnel.
        J Interv Card Electrophysiol. 2008; 21: 43-51
        • Woodhead J.
        • Harding S.A.
        • Simmonds M.
        • Dee S.
        • McBride-Henry K.
        Premedication for cardiac catheterization and percutaneous coronary intervention: does it increase vascular access site complications?.
        J Cardiovasc Nurs. 2007; 22: 466-471
        • Beddoes L.
        • Botti M.
        • Duke M.M.
        Patients’ experiences of cardiology procedures using minimal conscious sedation.
        Heart Lung. 2008; 37: 196-204
        • Deftereos S.
        • Giannopoulos G.
        • Raisakis K.
        • Hahalis G.
        • Kaoukis A.
        • Kossyvakis C.
        • et al.
        Moderate procedural sedation and opioid analgesia during transradial coronary interventions to prevent spasm: a prospective randomized study.
        JACC Cardiovasc Interv. 2013; 6: 267-273
        • Ashraf J.M.
        • Schweiger M.
        • Vallurupalli N.
        • Bellantonio S.
        • Cook J.R.
        Effects of oral premedication on cognitive status of elderly patients undergoing cardiac catheterization.
        J Geriatr Cardiol. 2015; 12: 257-262
        • Alamri H.
        • Almoghairi A.
        • Almasood A.
        • Alotaibi M.
        • Alonazi S.
        Do we need premedication before coronary angiography? A controlled clinical trial.
        Cardiol Res. 2011; 2: 224-228
        • Kiat Ang C.
        • Leung D.Y.C.
        • Lo S.
        • French J.K.
        • Juergens C.P.
        Effect of local anesthesia and intravenous sedation on pain perception and vasovagal reactions during femoral arterial sheath removal after percutaneous coronary intervention.
        Int J Cardiol. 2007; 116: 321-326
        • Fulton T.R.
        • Peet G.I.
        • McGrath M.A.
        • Hilton J.D.
        • Smith R.E.
        • Sigurdsson A.F.
        • et al.
        Effects of 3 analgesic regimens on the perception of pain after removal of femoral artery sheaths.
        Am J Crit Care. 2000; 9: 125-129
        • Wensley C.
        • Kent B.
        • McAleer M.B.
        • Savage S.M.
        • Stewart J.T.
        Pain relief for the removal of femoral sheath after percutaneous coronary intervention.
        Cochrane Database Syst Rev. 2008; (Art. No.: CD006043)
        • Ercan S.
        • Unal A.
        • Altunbas G.
        • Kaya H.
        • Davutoglu V.
        • Yuce M.
        • et al.
        Anxiety score as a risk factor for radial artery vasospasm during radial interventions: a pilot study.
        Angiology. 2014; 65: 67-70
        • Astarcioglu M.A.
        • Sen T.
        • Kilit C.
        • Durmus H.I.
        • Gozubuyuk G.
        • Agus H.Z.
        • et al.
        Procedural sedation during transradial coronary angiography to prevent spasm.
        Herz. 2016; 41: 435-438
        • Klockgether-Radke A.P.
        • Pawlowski P.
        • Neumann P.
        • Hellige G.
        Mechanisms involved in the relaxing effect of midazolam on coronary arteries.
        Eur J Anaesthesiol. 2005; 22: 135-139
        • Gursoy S.
        • Bagcivan I.
        • Yildirim M.K.
        • Berkan O.
        • Kaya T.
        Vasorelaxant effect of opioid analgesics on the isolated human radial artery.
        Eur J Anaesthesiol. 2006; 23: 496-500
        • Crews J.K.
        • Khalil R.A.
        Influence of morphine sulfate on cocaine-induced coronary vasoconstriction.
        Arterioscler Thromb. 1999; 90: 1034-1040
        • Okubo S.
        Ischemic preconditioning and morphine attenuate myocardial apoptosis and infarction after ischemia-reperfusion in rabbits: role of δ-opioid receptor.
        AJP Hear Circ Physiol. 2004; 287: H1786-H1791
        • Xu Q.
        • Li Q.-G.
        • Fan G.-R.
        • Liu Q.-H.
        • Mi F.-L.
        • Liu B.
        Protective effects of fentanyl preconditioning on cardiomyocyte apoptosis induced by ischemia-reperfusion in rats.
        Braz J Med Biol Res. 2017; 50: 1-11
        • Abdel-Wahab M.
        • Khattab A.A.
        • Liska B.
        • Kassner G.
        • Geist V.
        • Toelg R.
        • et al.
        Diazepam versus fentanyl for premedication during percutaneous coronary intervention: results from the myocardial protection by fentanyl during coronary intervention (PROFIT) trial.
        J Interv Cardiol. 2008; 21: 232-238
        • Rentoukas I.
        • Giannopoulos G.
        • Kaoukis A.
        • Kossyvakis C.
        • Raisakis K.
        • Driva M.
        • et al.
        cardioprotective role of remote ischemic periconditioning in primary percutaneous coronary intervention. enhancement by opioid action.
        JACC Cardiovasc Interv. 2010; 3: 49-55
        • Meine T.J.
        • Roe M.T.
        • Chen A.Y.
        • Patel M.R.
        • Washam J.B.
        • Ohman E.M.
        • et al.
        Association of intravenous morphine use and outcomes in acute coronary syndromes: results from the CRUSADE quality improvement initiative.
        Am Heart J. 2005; 149: 1043-1049
        • de Waha S.
        • Eitel I.
        • Desch S.
        • Fuernau G.
        • Lurz P.
        • Urban D.
        • et al.
        Intravenous morphine administration and reperfusion success in ST-elevation myocardial infarction: insights from cardiac magnetic resonance imaging.
        Clin Res Cardiol. 2015; 104: 727-734
        • Kundra T.
        • Nagaraja P.
        • Singh N.
        • Dhananjaya M.
        • Sathish N.
        • Manjunatha N.
        Effect of dexmedetomidine on diseased coronary vessel diameter and myocardial protection in percutaneous coronary interventional patients.
        Ann Card Anaesth. 2016; 19: 394
        • Snapir A.
        • Posti J.
        • Kentala E.
        • Koskenvuo J.
        • Sundell J.
        • Tuunanen H.
        • et al.
        Effects of low and high plasma concentrations of dexmedetomidine on myocardial perfusion and cardiac function in healthy male subjects.
        Anesthesiology. 2006; 105 (quiz 1069–70): 902-910
        • Lavi S.
        • Bainbridge D.
        • D’Alfonso S.
        • Diamantouros P.
        • Syed J.
        • Jablonsky G.
        • et al.
        Sevoflurane in acute myocardial infarction: a pilot randomized study.
        Am Heart J. 2014; 168: 776-783
        • Nascimento J.D.S.
        • Módolo N.S.P.
        • Carvalho H.G.
        • Dórea E.M.L.
        • Santos K.P.
        Clonidine in cineangiocardiography: sedative effects on blood pressure and heart rate.
        Arq Bras Cardiol. 2006; 87: 550-608
        • Rocha A.P.C.
        • Barros G.A.M.
        • Nascimento J.D.S.
        • Santos K.P.
        • Vasconcelos L.M.
        • Castro P.A.C.R.
        Sedation with sufentanil and clonidine in patients undergoing heart catheterization.
        Arq Bras Cardiol. 2011; 96: 219-226
        • Kubica J.
        • Adamski P.
        • Ostrowska M.
        • Sikora J.
        • Kubica J.M.
        • Sroka W.D.
        • et al.
        Morphine delays and attenuates ticagrelor exposure and action in patients with myocardial infarction: the randomized, double-blind, placebo-controlled IMPRESSION trial.
        Eur Heart J. 2016; 37: 245-252
        • Parodi G.
        • Bellandi B.
        • Xanthopoulou I.
        • Capranzano P.
        • Capodanno D.
        • Valenti R.
        • et al.
        Morphine is associated with a delayed activity of oral antiplatelet agents in patients with st-elevation acute myocardial infarction undergoing primary percutaneous coronary intervention.
        Circ Cardiovasc Interv. 2015; 8: 1-7
        • Hobl E.L.
        • Stimpfl T.
        • Ebner J.
        • Schoergenhofer C.
        • Derhaschnig U.
        • Sunder-Plassmann R.
        • et al.
        Morphine decreases clopidogrel concentrations and effects: a randomized, double-blind, placebo-controlled trial.
        J Am Coll Cardiol. 2014; 63: 630-635
        • Montalescot G.
        • van’t Hof A.W.
        • Lapostolle F.
        • Silvain J.
        • Lassen J.F.
        • Bolognese L.
        • et al.
        Prehospital ticagrelor in ST-segment elevation myocardial infarction.
        N Engl J Med. 2014; 371: 1016-1027
        • McEvoy J.W.
        • Ibrahim K.
        • Kickler T.S.
        • Clarke W.A.
        • Hasan R.K.
        • Czarny M.J.
        • et al.
        Effect of intravenous fentanyl on ticagrelor absorption and platelet inhibition among patients undergoing percutaneous coronary intervention: the PACIFY randomized clinical trial.
        Circulation. 2017; 5857 (CIRCULATIONAHA.117.031678)
        • Drug Interactions
        MIMS online.
        (Retrieved from
        • Naidu S.S.
        • Aronow H.D.
        • Box L.C.
        • Duffy P.L.
        • Kolansky D.M.
        • Kupfer J.M.
        • et al.
        SCAI expert consensus statement: 2016 best practices in the cardiac catheterization laboratory.
        Catheter Cardiovasc Interv. 2016; 88: 407-423
        • American Society of Anesthesiologists
        Statement on granting privileges for administration of moderate sedation to practitioners who are not anesthesia professionals.
        • Australian and New Zealand College of Anaesthetists
        Guidelines on sedation and/or analgesia for diagnostic and interventional medical, dental or surgical procedures (PS09).
        • Australian and New Zealand College of Anaesthetists
        Guidelines on monitoring during anaesthesia (PS18).
        • American Society of Anesthesiologists
        Standards for basic anesthetic monitoring.
        • Conway A.
        • Douglas C.
        • Sutherland J.R.
        A systematic review of capnography for sedation.
        Anaesthesia. 2016; 71: 450-454
        • Mehta P.P.
        • Kochhar G.
        • Albeldawi M.
        • Kirsh B.
        • Rizk M.
        • Putka B.
        • et al.
        Capnographic Monitoring in routine EGD and colonoscopy with moderate sedation: a prospective, randomized.
        Controlled Trial. 2016; : 1-10
        • Sheahan C.G.
        • Mathews D.M.
        Monitoring and delivery of sedation.
        Br J Anaesth. 2014; 113: ii37-ii47
        • Mancuso C.E.
        • Tanzi M.G.
        • Gabay M.
        Paradoxical reactions to benzodiazepines: literature review and treatment options.
        Pharmacotherapy. 2004; 24: 1177-1185
        • American Society of Anesthesiologists Task Force
        Practice guidelines for sedation and analgesia by non-anesthesiologists.
        Anesthesiology. 2002; 96: 1004-1017