Low Incidence of Intubation During PCI Challenges Need for Universal Preprocedural Fasting: JAHA

"Key predictors of intubation included cardiogenic shock, out-of-hospital cardiac arrest, femoral access, left main disease, type C lesions, and the use of rotational atherectomy," the researchers reported in the Journal of the American Heart Association.

Percutaneous coronary intervention is a widely used procedure to address coronary artery disease, often requiring sedation or anesthesia. Preprocedural fasting is a common practice before PCI. However, the frequency of procedural intubation during PCI remains unclear. Therefore, Sean Tan, Monash Heart Victorian Heart Hospital, Monash Health Melbourne Australia, and colleagues seek to determine the incidence of procedural intubation and identify its key predictors.

For this purpose, the researchers conducted a retrospective cohort study involving patients who underwent PCI between 2014 and 2021, as recorded in the Victorian Cardiac Outcomes Registry. Patients were categorized based on PCI indication into urgent, semi-urgent, or elective groups. It was assumed that those undergoing semi-urgent or elective PCI had adhered to preprocedural fasting protocols. The incidence of procedural intubation was analyzed for each group.

Inverse probability treatment weighting was applied to assess the relationship between procedural intubation and 30-day mortality. Additionally, logistic regression was used to identify clinical, procedural, and lesion-related factors associated with procedural intubation among fasted patients.

The following were the key findings of the study:

• Among 83,929 patients, the incidence of procedural intubation was 0.5%.

• Patients undergoing urgent PCI had the highest risk of procedural intubation (OR 19.68).

• Procedural intubation was associated with an increased risk of 30-day mortality (OR 4.79).

• Among fasted patients, the following factors were associated with procedural intubation:

• Estimated glomerular filtration rate (OR 0.99).

• Cardiogenic shock (OR 96.24).

• Out-of-hospital cardiac arrest (OR 3.42).

• Femoral access (OR 2.09).

• Left main disease (OR 5.77).

• Type C lesions (OR 3.86).

• Rotational atherectomy (OR 2.20).

The study showed that the incidence of procedural intubation among patients undergoing PCI was low.

"Although procedural intubation was linked to an increased risk of 30-day mortality, its rarity indicates that universal strict preprocedural fasting may not be essential for all patients. Instead, preprocedural fasting could be selectively advised for those undergoing elective or semiurgent PCI who are identified as having higher clinical or procedural risks for intubation," the researchers concluded.

Reference:

Herson M, Tan S, O'Brien J, Teoh ZH, Manmathan GPR, Dinh D, Brennan A, Brown AJ, Chew DP. Assessing the Likelihood of Procedural Intubation During Percutaneous Coronary Intervention. J Am Heart Assoc. 2025 Jan 16:e038092. doi: 10.1161/JAHA.124.038092. Epub ahead of print. PMID: 39817559.