Rapid Desensitization to Overcome Contrast Allergy Prior to Urgent Coronary Angiography

Abstract

SummaryAllergic reactions to contrast media are a frequently reported complication of coronary angiography. The majority of patients experience mild, self-limited episodes, but in rare cases patients may experience severe, persistent symptoms. A strategy of premedication with corticosteroids and anti-histamines and an optimal selection of contrast agent is almost always successful in averting contrast reactions, yet a select few patients will continue to have breakthrough events. This is a case of recurrent, severe allergy to contrast media despite standard precautions complicating the treatment of non-ST elevation myocardial infarction (NSTEMI). Our patient was successfully managed with a strategy of rapid desensitization to iodinated contrast media achieved by administering progressively incremental doses of the media.(Int Heart J Advance Publication) Key words: Coronary artery disease, Chemotoxic reaction, Anaphylactoid reaction M inor allergic reactions to contrast media are a frequently reported complication of coronary angiography though severe allergic reactions are much less common. Such events are typically prevented with premedication and selection of appropriate contrast media prior to the procedure. Here we present a case of refractory, severe allergic reaction to contrast media during coronary angiography that was successfully managed with a desensitization protocol. Case ReportThe patient was a 67-year-old man with a history of non-obstructive coronary artery disease (CAD) diagnosed 3 years previously on a coronary angiogram that demonstrated a 50% stenosis in the mid left anterior descending artery (LAD), pacemaker placement for complete heart block (CHB), asthma and bladder cancer who was initially admitted to our affiliated Veterans Hospital for a planned cystoscopy/retrograde pyelogram. While in recovery in the post-anesthesia care unit he informed his nurse of intra-operative chest pain that had since resolved. An electrocardiogram (ECG) was unchanged from baseline. His first troponin was 0.18. He was started on dual antiplatelet therapy and anticoagulation and continued on his beta-blocker and statin. His troponin peaked at 0.20 the following day. Urgent revascularization for NSTEMI was scheduled for the following morning.Pre-catheterization evaluation revealed a significant history of allergic reaction to contrast media. In early 2013 the patient developed nausea and an erythematous, pruritic rash following a contrast-enhanced CT scan of the abdomen and pelvis. A contrast allergy was added to his medical record. He was scheduled for coronary angiography later that year, and was pretreated with oral prednisone 50 mg (13 hours, 7 hours and 1 hour pre-procedure), as well as oral diphenhydramine (1 hour pre-procedure). Despite pretreatment he developed severe nausea and pruritus, with scattered erythema and bullae noted on exam. He was treated with intravenous methylprednisolone, famotidine, and diphenhydramine, and monitored in the ICU for 2 days. He was hospitalized again in 2014 after develop...

Radiologic Contrast Media Desensitization for Delayed Cardiac Catheterization

“…2 Life-threatening conditions, such as anaphylactoid reactions, manifest in less than 0.1% of patients traditionally with high-osmolality contrast. 2…”

“…2 Although readministration of the final dose was considered in the protocol described by Uppal et al. to avoid contrast-induced nephropathy (CIN), 2 our risk score calculations suggested that the patient was at low risk of nephropathy that did not necessitate reduced dosage. 5 This RCM desensitization was conducted in an intensive care unit.…”

“…The patient previously described by Uppal et al required a repeat catheterization due to unstable angina with RCM desensitization 2 years after the initial procedure. 2 The patient was pretreated with prednisone, diphenhydramine (Bendaryl V R ), and ranitidine. Following the protocol reported by Uppal et al, 2 the patient tolerated doses 1 and 2 and subsequently developed pruritus minutes after the third dose (Table 1).…”

“…Several studies offer data on the efficacy of RCM desensitization for medical emergencies, such as cardiac catheterization. [2][3][4] Frequently, the cardiac catheterization schedule does not accommodate the RCM desensitization protocol. We propose an RCM desensitization protocol to meet the catheterization schedule without losing the protective nature of the desensitization.…”

Additional Value of Early Repolarization Pattern in Prediction of Obstructive Coronary Artery Disease as Assessed by Coronary Angiography

“…The presence of coronary stenosis was anatomically assessed based on a modified model of the coronary tree with 15 segments. 16,17) The stenotic lesions were evaluated and described as the percentage of lumen diameter reduction. Significant or obstructive CAD was primarily defined as stenosis !50% in any major epicardial coronary artery, although the other typical definition of obstructive CAD using the alternative cut-off of a stenosis diameter of !70% was also tested.…”