Year

2023

Degree Name

Doctor of Philosophy

Department

School of Nursing

Abstract

Background: Coronary artery disease, involving stenoses of the coronary vasculature, is a major contributor to cardiovascular disease (CVD) morbidity and mortality in Australia. Cardiac catheterisation is a key strategy in the management and diagnosis of coronary artery disease. This procedure is rapidly evolving as new knowledge and technological advancements change practice. Such rapid evolution has created challenges in sustaining the evidence base to guide best practice.

Current recommendations suggest the use of the radial artery to gain access for the procedure. Despite the current emphasis on radial artery access, the prevalence of radial artery spasm (RAS) poses a notable challenge with rates of up to 30% reported for transradial cardiac catheterisation procedures potentially affecting the success rates of the procedure and causing considerable discomfort for patients. Hence, understanding and mitigating RAS has become increasingly critical in optimising patient outcomes and procedural success.

Aim: This Doctoral project sought to gain greater insight into the management of RAS in transradial cardiac catheterisation. This overarching aim was achieved through a series of distinct yet interrelated studies which sought to;

  1. review the current literature on pharmacotherapy to reduce the occurrence of RAS during transradial cardiac catheterisation.
  2. identify the predictors of RAS and the pharmacotherapy used for its prevention and management.
  3. map current practices and explore factors that influence clinical decision-making for transradial cardiac catheterisation.

Methods: A creative approach was used consisting of three separate yet interrelated phases. Phase one included two systematic reviews of current evidence for the management of RAS. Phase two comprised a quantitative descriptive study to identify medications and practices implemented to reduce the occurrence of RAS. Finally, in phase three, a sequential mixed methods study was carried out, focusing on current practice and clinical decision-making for interventional cardiologists.

Findings: Findings from the initial systematic reviews demonstrated that there is currently no preferred pharmacotherapy for the reduction of RAS.

Phase two presented data on 169 patients undergoing cardiac catheterisation across two institutions. Twenty-four (14%) patients were reported to have experienced RAS during the procedure. Radial artery spasm was significantly higher in females (66.6%, p=0.004), those under the age of 65 years (62.5%, p=0.001) and those who reported a medical history of anxiety (33.3%, p=0.0004). Logistic regression identified younger age as the only statistically significant predictor of RAS (OR 0.536; 95% CI 0.171 to 1.684; p=0.005).

Phase three incorporated survey data from 45 cardiac interventionalists, followed by interviews with eight interventionalists currently practising in Australia and New Zealand. Over a third (37%) of respondents indicated that they performed some form of test to assess hand circulation before the procedure. The majority (77.8%) of respondents estimated that they experienced RAS in approximately 10% of the transradial procedures. While over a third (38%) of respondents carry out no test to identify radial artery occlusion post-procedure. Interventionalists identified four main themes that contribute to their clinical decision-making. These were decisionmaking based on research, using clinical experience, being led by their training and individual patient factors.

Discussion: There is a lack of high-quality evidence to support clinical recommendations or guidelines for RAS resulting in variations in clinical practice. Interventionalists have to rely, on experience and other methods of decision-making for their clinical practice. The findings indicate the multifaceted nature of RAS management and the need for strong high-certainty clinical guidelines.

Conclusion: Currently there is insufficient evidence to support a single approach to reduce RAS. As cardiac catheterisation has evolved at a rapid pace interventionalists cannot make clinical decisions based solely on existing evidence. Continued research is required to produce high-quality evidence to support the generation of strong, high-certainty clinical recommendations and guidelines.

FoR codes (2020)

420501 Acute care, 320101 Cardiology (incl. cardiovascular diseases)

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Unless otherwise indicated, the views expressed in this thesis are those of the author and do not necessarily represent the views of the University of Wollongong.