Fasting not necessary for cardiac catheterization procedures with conscious sedation
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Key takeaways:
- Not fasting before cardiac catheterization procedures with conscious sedation was just as safe as fasting.
- Patients who did not fast had better satisfaction scores than those who did.
Not fasting before cardiac catheterization procedures with conscious sedation was noninferior and likely superior to fasting for safety, and improved patient satisfaction, researchers reported at the European Society of Cardiology Congress.
Fasting before cardiac catheterization procedures with any type of anesthesia has been common practice, and was reaffirmed in the 2023 Practice Guidelines for Preoperative Fasting from the American Society of Anesthesiology, but some single-center studies, starting with the CHOW NOW trial, presented at the 2020 virtual Society for Cardiovascular Angiography and Interventions Scientific Sessions, found no significant difference in adverse events with standard fasting compared with unrestricted oral intake, David Ferreira, MD, interventional cardiologist at John Hunter Hospital, Newcastle, New South Wales, Australia, said at the ESC Congress.
‘Bread-and-butter cardiology’
“This is bread-and-butter cardiology,” he said during a press conference. “Millions of patients undergo coronary device-related procedures every year, and so this is an important clinical question. Therefore, we designed and performed a multicenter randomized trial across sites in Australia and randomly allocated half [of patients] to no fasting and half to fasting as recommended by current guidelines, which is 6 hours of solid food fasting and 2 hours of clear liquid fasting.”
The SCOFF trial, simultaneously published in the European Heart Journal, included 716 patients (mean age, 70 years; 65% men) undergoing a cardiac catheterization procedure with conscious sedation. The average solid food fasting was 13.2 hours in the fasting arm vs. 3 hours in the no fasting arm, and the average clear liquid fasting was 7 hours in the fasting arm vs. 2.4 hours in no fasting arm, and the Bayes factor for both exceeded 100, indicating extreme evidence of difference, according to the researchers.
Ferreira said some patients were “sad” when they found out they were going to be in the fasting arm.
The primary outcome, a composite of aspiration pneumonia, hypotension, hyperglycemia and hypoglycemia assessed with a Bayesian approach, occurred in 19.1% of patients in the fasting arm and 12% of patients in the no fasting arm (estimate of mean posterior difference in proportions, –5.2%; 95% CI, –9.6 to –0.9; relative difference, 0.68; 95% credible interval, 0.46-0.91; posterior probability of noninferiority > 99.5%; posterior probability of superiority = 99.1%), Ferreira said at the press conference.
There were no cases of aspiration pneumonia, but all other components of the primary outcome were numerically lower in the no fasting group, he added.
Patient satisfaction scores were better in the no fasting group (posterior mean difference, 4.02 points; 95% CI, 3.36-4.67; Bayes factor > 100), he said.
There were no significant differences between the groups in contrast-induced nephropathy, new ventilation requirement, new ICU admission, 30-day readmission, 30-day death or 30-day pneumonia, according to the researchers.
‘The evidence has shifted’
“Removing fasting requirements does appear safe, and potentially looks better than fasting for the outcomes that we tested for,” Ferreira said at the press conference. “Removing fasting requirements also improved patient satisfaction. It’s important to recognize that the SCOFF trial doesn’t stand alone. We have multiple single-center randomized controlled trials ... all with a consistent message: Removing fasting requirements does not appear to be associated with adverse procedural events, and appears also to be associated with improved patient satisfaction. With this new evidence, and the evidence that has come before, I do think now that the evidence has shifted, and I would suggest that removing fasting requirements is safe and improves patient satisfaction for the procedures that were enrolled in the trial.”
When asked about what needs to be done to change a practice that has existed for so long, Ferreira said performing a meta-analysis of all the fasting vs. no fasting trials could “increase the precision of the results,” and to convey the message that “we are not advocating that we need patients to be force fed. Maybe they can drink their coffee with a little milk to avoid the withdrawal headache we all get in the mornings. Maybe they can drink water as they please while they await their cardiac catheterization that has been delayed due to urgent case after urgent case. While there may be some clinical inertia, when we understand the patient’s perspective, hopefully that can help overcome some of that.”
Reference:
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Ferreira D, et al. Hot line 8. Presented at: European Society of Cardiology Congress; Aug. 30-Sept. 2, 2024; London (hybrid meeting).
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