Clinical Radiolog)~. (1980) 31, 291-295 1980 l~oyat uottege of Radiologists

0009-9260/80/00070291502.00

Arrhythmias Occurring During Intravenous Urography ANTHONY OWENS and MARY ENNIS

Department o f Radiology, St Vincent's Hospital, Elm Park, Dublin 4, Ireland

A low but significant fatality rate persists in intravenous urography. Fatalities are sudden and their cause is not understood. This trial assessed the arrhythmogenic effects of a common urographic contrast agent. Using standard bolus injection techniques, 12 patients out of 58 (20%) developed post-injection arrhythmias. Seven of these cases (12%) were considered to have significant or potentially serious arrhythmias. This group includes various paroxysmal tachycardias and a case of atrioventricular block. Arrhythmia post-injection was commoner in the male and in the older age groups. An abnormal control ECG was not found to be a predis- posing factor to the development of arrhythmia. It is suggested that the Findings reflect the high incidence of latent coronary heart disease in our older male population. No correlation was found with minor side-effects of contrast injection and the development of arrhythmia.

High dose excretion urography remains the accepted method of investigating the urinary tract, despite the incursions of CT, ultrasound and nuclear scanning. Although the newer contrast agents have fewer side- effects, there is an undoubted morbidity and a re- ported mortality factor from the rapid intravenous injection of these substances (Pendergrass et al., 1958; Fischer and Doust, 1972).

These sequelae can be divided into minor and major side-effects. The minor reactions are easily countered by the use of appropriate therapy. The major side-effects, which can be life-threatening (Ansell, 1970), pose problems for every diagnostic X-ray department. The prevention and treatment of such catastrophes form a continuing challenge to the practising diagnostic radiologist.

The cause of sudden death, which transcends all age groups, is not dearly understood in the above context. Various factors have been cited, such as anaphylaxis, neurogenic stimulation, osmotic distur- bance, direct toxicity and sudden cardiac arrest (Lindgren, 1970).

The recent association between cardiac arrhy- thmias and the rapid injection of intravenous contrast medium highlights one area of major importance in

our understanding of this mortality (Small and Glenn, 1968; Berg et al., 1973; Stadalnik et al., 1977). Arrhythmias have been reported to occur more fre- quently in patients who have coronary heart disease, who are in heart failure, or who have an abnormal resting ECG (Stadalnik et al., 1977). No significant difference in the frequency of arrhythmias has been noted with the different contrast agents, although sodium salts are generally considered more toxic.

This trial assesses the arrhythmogenic effects of Urovision on an unselected group of patients referred for excretion urography.

PATIENTS AND METHODS

A total of 58 patients were admitted to the study (Table 1). There was no attempt to select the patients on the basis of age, sex or previous medical history. All patients were interrogated according to a standard protocol (Table 2).

Each patient was injected with 50 ml of Urovision. This contrast medium is a mixture of the sodium and meglumine salts of diatrizoic acid in the ratio of 50 :18 in aqueous solution. The iodine content is

T a b l e 1 - P a t i e n t s in t r ia l - a g e a n d sex

Age (years) Total

0-19 20-29 30-39 40-49 50-59 60-69 70 79+

Males 0 3 3 7 5 6 6 30 Females 1 6 3 8 7 3 0 28

Total 1 9 6 15 12 9 6 58

292 C L I N I C A L R A D I O L O G Y

Table 2 - Protocol for patients in trial

Name Sex Age Weight Hosp. no. X-ray no. Date o f in/ection

Doctor Contrast (consultant) medium

Dose

Previous IVP?

Other relevant illnesses?

'Reaction' to present IVP? Specify treatment

Reason for present IVP

AHergies?

Current medications

Nature o f previous reaction to IVP

Comment on ECG during and after IVP

In/ec~'on tim, (~1

History o f cardiac disease and detaih ~

Comment on control EC(

Other observations

(Signature of person injecting)

325 mg/ml, and the standard ampoule therefore con- tains 16.25 g of iodine. The injection was carried out using a 19-gauge needle over a 10 s period in all cases. Prior to this injection, each patient had a 12-lead electrocardiogram performed which contained an ample number of complexes to display any arrhyth- mias. Continuous rhythm tracings were obtained during and for at least 1 min after the administration of the contrast medium.

RESULTS

Although a number of patients experienced minor reactions such as nausea, retching, flushing, taste disturbances and urticaria, no clinical side-effects were encountered. The electrocardiographic results were divided into three groups:

(a) Normal Electrocardiographs

Forty-six patients (80%) showed no rhythm altera- tion between pre- and post-injection electrocardio- graphs, although seven of these patients had an abnormal control electrocardiograph.

(b) Minor Arryhythmias Five patients developed minor arrhythmia changes

(Table 3). In four of these patients the control electrocardiograph was normal. These arrhythmias included isolated atrial and ventricular ectopics.

(c) Potentially Serious Arrhythmias Seven patients (Table 4) developed a potentially

serious arrhythmia following injection. Six of these seven had a normal pre-injection electrocardiograph. Serious arrhythmias were considered to include multiple eetopie beats, paroxysms of tachy. arrhythmia or atrioventrieular block (Figs 1-5).

Sinus arrhythmias or sinus tachycardias were not considered as arrhythmias in this trial. There was no correlation between the development of arrhyttunia and the onset of minor side-effects. The age and s0x difference was significant. The average age of patients in the trial was 48.4 years, while the average age of patients developing arrhythmia was 57 years. The average age of patients not developing arrhythmia was 46.2 years. Ten of the 12 patients who manifest0d arrhythmia changes were male.

A R R H Y T H M I A S O C C U R R I N G D U R I N G I N T R A V E N O U S U R O G R A P H Y

Talkie 3 - Minor arrhythmias noted

293

Age Sex Heart disease or Allergy Control ECG Post-injection case hypertension tracings

15 F - - Normal 1 63 M Hypertension - Minor ischaemic 2 changes

74 M - - Normal 3

75 M - - Normal

57 M - Pollens, dust, Normal 5 etc.

Table 4 - Potentially serious arrhythmias noted

Case Age Sex Heart disease or Allergy Control ECG Post-injection hypertension tracings

Transient SA block Isolated ventricular

ectopic Isolated atrial

ectopic Isolated atrial

ectopic Isolated ventricular

ectopic

6 49 F - - Normal Transient atrial tachyarrhythmia

7 48 M Hypertension - Normal 2/1 A/V block + (untreated) atrial ectopics

8 55 M - - Normal Multiple atrial and ventricular ectopics

9 78 M - - Normal Transient atrial bigeminal rhythm

10 66 M Ischaemic heart - Isehaemic Transient atrial tachyar- disease rhythmia

11 45 M - Penicillin Normal Multiple ventricular ectopics

12 58 M - - Normal Transient atrial tachyar- rhythmia

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7 Fig. 1 (top) - Case 12, 50-year-old male. Control ECG normal. Transient atrial tachyarrhythmia post-injection. Fig. 2 (bottom) _ Case 6.49-year-old female. Control ECG normal. Transient atrial taehyarrhythmia post-injection.

294 CLINICAL R A D I O L O G Y

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Fig. 4 (top) - Case 9, 78-year-old male. Normal control ECG. Transient atrial bigeminal rhythm post-injection. Fig. 5 (bottom) - Case 10, 66-year-old male. Ischaemia on control ECG. Transient atrial taehyarrhythmia post-injection.

DISCUSSION

Mortality from excretion urography has dropped significantly with the use of modem contrast agents. It does occur, however, and the results of this trial

highlight one area which is a contributory factor with few or no clinical manifestations. The patient with atrioventricular block, although transient, produced an example of a serious arrhythmia which could give rise to morbidity. This arrhythmia has not previously

ARRHYTHMIAS OCCURRING DURING INTRAVENOUS UROGRAPHY 295

been described during excretion urography. The high s~ale predilection and the more advanced years o f the arrhythmia group are probably indicators o f the high prevalence of latent coronary artery disease in that population. The status o f the pre-injection electro- cardiograph provided no indication o f the likely development of an arrythmia, and would not seem to be warranted as a routine procedure. The results suggest that particular caution be exercised when hajecting contrast medium intravenously in the older, male patient. The effect o f the rate o f injection and of the different types o f contrast media are at present being more fully investigated.

REFERENCES

Ansell, G. (1970). Adverse reactions to contrast agents: scope of problem. [nvesn'gative Radiology, 5, 374-384.

Berg, G. R., Hutter, A. M. & Pfister, R. C. (1973). Electro- cardiographic abnormalities associated with intravenous urography. New England Journal of Medicine, 289, 87- 88.

Fischer, H. W. & Doust, V. B. (1972). An evaluation of pre- testing in the problem of serious and fatal reactions to excretory urography.Radiology, 103,497-501.

Lindgren, P. (1970). Haemodynamic responses to contrast media. Investigative Radiology, 5,424-435.

Pendergrass, H. P., Tondreau, R. L., Pendergrass, E. P., Ritchie, D. J,, Hildreth, 13. A. & Askovitz, S. I. (1958). Reactions associated with intravenous urography: historical and statistical review. Radiology, 71, 1-2.

Small, M. P. & Glenn, J. F. (1968). Comparative evaluation of intravenous pyelographic contrast media and assess- ment of associated electrocardiographic alterations. Journal of Urology, 99, 223 -225.

Stadalnik, R. C., Zakauddin, B., Da Silva, O., Davies, R., Kraus, J. F. & Mason, D. T. (1977). Electrocardiographic response to intravenous urography: prospective evaluation of 275 patients. American Journal o] Roentgenology, 129, 825-830.