Contrast-Related Acute Pulmonary Edema Following Diagnostic Coronary Angiography: A Case Report

Acute pulmonary edema (APE) secondary to diagnostic angiography is an uncommon complication of the procedure. It may result from several factors, including underlying congestive cardiac failure with poor left ventricular (LV) systolic function, baseline fluid overload, excessive use of contrast during diagnostic angiography in patients with severe coronary artery disease and LV impairment, and, very rarely, an anaphylactoid reaction to iodine-containing intravenous contrast agents. We report the case of a 60-year-old man who presented to the ED with an intermittent history of worsening nonexertional chest pain associated with breathlessness, occasionally relieved by rest and/or glyceryl trinitrate (GTN) spray. The chest pain was also worse following heavy meals. Due to the infrequent nature of his symptoms, he was seen in a cardiology clinic and referred for an urgent outpatient CT coronary angiogram, which suggested three-vessel disease, primarily involving the right coronary artery and left anterior descending artery, with milder disease in the left circumflex artery. Echocardiography revealed mildly reduced LV systolic function (LV ejection fraction = 45%). In the weeks leading up to his invasive angiogram, he noted mild ankle swelling and orthopnea, for which his general practitioner prescribed oral furosemide 40 mg daily for two weeks. He appeared euvolemic on the day of the angiogram. The coronary angiogram was uneventful, confirming severe multivessel coronary disease. Within 10 minutes of the procedure, the patient developed APE, suspected based on subtle angiographic findings, physical examination, and chest X-ray. He was promptly started on intravenous GTN infusion and made a good clinical recovery within 48 hours. He was later transferred to a tertiary center for coronary artery bypass graft surgery.