Challenging a Decades-Old Standard: Fasting Prior to Cardiac Procedures Seems Unnecessary, AHJ Study, December 2025

The authors advocate that more studies are needed to better understand these differences.

The Rationale vs. Reality of Pre-Procedural Fasting

Pre-procedural fasting before cardiac catheterization remains common, despite limited evidence supporting the practice. The original rationale—reducing aspiration risk during potential general anesthesia, is weak because aspiration events are exceedingly rare, and emergency surgery after PCI occurs in <0.1% of cases. Moreover, studies show no correlation between fasting duration and gastric volume or acidity. Prolonged fasting (>12 hours) may even be harmful, increasing the risk of contrast-induced nephropathy, hypoglycemia, dehydration, and lowering patient satisfaction.

About the Systematic Review

The authors conducted a systematic review and meta-analysis to assess the safety and patient well-being outcomes of a non-fasting strategy compared to a fasting strategy. The analysis specifically included eight randomized controlled trials (RCTs) published between 2017 and 2024, enrolling a total of 3,382 patients. Inclusion criteria focused on procedures requiring minimal to moderate sedation, such as coronary angiography, PCI, right/left heart catheterization, and electrophysiology device-related procedures. Studies involving transcatheter valve procedures or deep sedation were explicitly excluded due to variability in sedation protocols.

Primary safety outcomes analyzed included nausea, vomiting, aspiration, intubation, hypoglycemia, hypotension, and acute kidney injury (AKI). Secondary outcomes were patient satisfaction score and length of hospital stay.

Key Results from the Study include:

The pooled analysis of 3,382 patients confirmed that there was no significant difference in most major safety outcomes (nausea and vomiting and aspiration) between the fasting and non-fasting cohorts.

• The incidence of hypoglycemia and hypotension also showed no significant difference. Numerically, hypotension and hypoglycemia occurred more often in the fasting group, likely attributable to decreased intravascular volume and dehydration.
• Critically, zero incidents of endotracheal intubation were reported in either group across the large patient cohort, suggesting the likelihood of this outcome is extremely rare and should not be a deciding factor in fasting policy.

• Secondary outcomes, including patient satisfaction scores and length of hospital stay, also showed no significant difference between the two strategies.

• However, a sub-group analysis provided two key signals: the odds of nausea/vomiting were modestly but statistically significantly increased in the fasting group compared to non-fasting. Conversely, this sub-group analysis showed a statistically significant reduction in the odds of acute kidney injury (AKI) in the fasting group, though the authors noted this result was unexpected and potentially influenced by definitions of AKI or increased hydration in the fasting group.

Potential Clinical Ramification

This meta-analysis provides the most robust evidence to date confirming the safety of a non-fasting strategy for elective cardiac procedures under moderate sedation. For practicing cardiologists, the findings suggest that the routine policy of mandatory fasting—which averaged 880 minutes in the pooled fasting cohort—should be questioned.

The fact that aspiration rates are extremely low and comparable between groups, combined with zero intubation events, validates the notion that keeping patients fasting does not make the procedure safer. Given the statistically increased risk of nausea and vomiting associated with fasting, promoting a liberal oral intake approach could potentially increase patient comfort and reduce administrative burden without compromising safety.

More robust studies are needed to further substantiate these findings.

Reference: Pir MS, Mitchell BK, Saqib NU, Saleem MS, Gertz ZM. Safety of oral intake prior to cardiac catheterization with minimal to moderate sedation: A systematic review and meta-analysis of randomized controlled trials. Am Heart J. 2025 Dec;290:188-200. doi: 10.1016/j.ahj.2025.06.019. Epub 2025 Jul 1. PMID: 40609715.

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