Highlight
- Systematic review and meta-analysis of 8 randomized controlled trials (N=3,382) evaluating fasting versus nonfasting prior to cardiac catheterization under minimal to moderate sedation.
- No significant difference in primary safety outcomes including nausea/vomiting, aspiration, hypoglycemia, hypotension, and acute kidney injury between fasting and nonfasting groups.
- No cases of intubation reported in either group, indicating a very low risk of airway compromise with nonfasting.
- Subgroup analyses suggest potential increased nausea/vomiting with fasting and decreased acute kidney injury, but overall clinical impact remains uncertain.
Study Background
Percutaneous cardiac interventions, including diagnostic cardiac catheterization, often require sedation to ensure patient comfort and procedural success. Traditionally, patients are advised to fast prior to such procedures to minimize the risk of pulmonary aspiration and other complications. However, this fasting practice is largely based on extrapolations from general anesthesia guidelines rather than high-quality evidence specific to procedures performed under minimal to moderate sedation.
Fasting can lead to patient discomfort, hypoglycemia, hypotension, and delays in care. Moreover, prolonged fasting may also impact patient satisfaction and metabolic stability. Given the increasing volume of cardiac catheterizations worldwide and evolving sedation practices, reexamining the necessity and safety of preprocedural fasting is clinically important.
Study Design
This systematic review and meta-analysis by Pir et al. aggregated data from eight randomized controlled trials involving 3,382 patients undergoing cardiac catheterization with minimal to moderate sedation. The included studies compared outcomes in patients who were either fasted or allowed oral intake prior to the procedure.
The primary endpoints analyzed were nausea, vomiting, aspiration events, endotracheal intubation, hypoglycemia, hypotension, and acute kidney injury. Secondary outcomes included patient satisfaction scores and length of hospital stay. The authors employed rigorous search strategies across Medline, Cochrane CENTRAL, and Google Scholar databases. Quantitative synthesis used random-effects meta-analytic models in R software.
Key Findings
Nausea and Vomiting
Seven studies reported nausea and vomiting incidents, yielding a pooled odds ratio (OR) of 0.99 (95% CI, 0.68–1.45), indicating no significant difference between fasting and nonfasting groups. The low heterogeneity (I² = 0%) strengthens confidence in this finding. Interestingly, a subgroup analysis showed increased odds of nausea/vomiting in the fasting group (OR 1.20, 95% CI 1.04–1.39), suggesting fasting might paradoxically elevate these symptoms.
Hypoglycemia
Five studies evaluated hypoglycemia, with a pooled OR of 1.28 (95% CI, 0.75–2.18) showing no statistically significant difference. This suggests that allowing oral intake does not increase hypoglycemia risk in the peri-procedural setting.
Aspiration and Intubation
Aspiration events were rare and not significantly different between groups (OR 0.72, 95% CI, 0.36–1.43). No endotracheal intubations were reported across any studies, implying that minimal to moderate sedation with either fasting or nonfasting poses negligible risk for airway compromise. These data contest the conventional rationale for strict fasting to prevent aspiration in this context.
Acute Kidney Injury (AKI)
Five studies reported on AKI incidence. The pooled OR was 0.69 (95% CI, 0.38–1.23) with no significant overall difference. However, subgroup analysis indicated a decreased odds of AKI in the fasting group (OR 0.50, 95% CI, 0.28–0.89). While intriguing, this requires cautious interpretation given potential confounders and limited power.
Hypotension
Data from three studies showed no significant difference in hypotension risk (OR 1.57, 95% CI, 0.47–5.30) between fasting and nonfasting groups, though heterogeneity was moderate.
Length of Hospital Stay and Patient Satisfaction
No significant difference was observed in length of hospital stay (standardized mean difference 0.0, 95% CI, –0.6 to 0.7) or patient satisfaction scores (SMD 0.23, 95% CI –0.62 to 1.07) between strategies.
Expert Commentary
These findings challenge entrenched clinical practices that mandate fasting before cardiac catheterization under minimal to moderate sedation—procedures inherently less invasive than general anesthesia cases. The very low incidence of aspiration and absence of intubation events underscore the safety of liberalizing pre-procedural oral intake.
The noted potential increased nausea and vomiting in fasted patients may be related to metabolic and hormonal changes triggered by fasting states, which could paradoxically impair patient comfort. The signal for decreased AKI risk with fasting remains inconclusive but worth future investigation, possibly relating to hydration status or metabolic effects of fasting.
The main limitations include variability in fasting definitions, sedation protocols, and procedural complexity across studies, which may affect generalizability. Further large-scale, pragmatic trials with standardized protocols and detailed patient stratification are needed to confirm these findings and optimize guidelines.
Conclusion
This rigorous meta-analysis demonstrates no significant safety disadvantage in allowing oral intake prior to cardiac catheterization under minimal to moderate sedation compared with conventional fasting. The data encourage reconsideration of routine fasting policies, potentially improving patient comfort without increasing procedural risk.
Clinicians should balance the low risk of aspiration and other complications with patient-specific factors. Individualized fasting guidelines may promote safer, more patient-centered care in interventional cardiology.
Funding and Clinical Trials Registration
This study was funded by institutional grants as reported by the original authors. No clinical trials registration is cited.
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.
