A
recent systematic review and meta-analysis concluded that there is no
significant difference in most safety outcomes between a fasting and a non-fasting
strategy prior to percutaneous cardiac procedures with potential increase in
nausea/vomiting and decrease in acute kidney injury with fasting.

This
systematic review and meta-analysis was published in the American Heart Journal in 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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