Chest pain interventions
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Aisha Adigun, B.Sc., M.D.[3]
Overview
Common indications of coronary angiography in high risk ACS patients include new ischemic changes on the ECG , troponin-confirmed acute myocardial injury , new-onset left ventricular systolic dysfunction (ejection fraction <40%) , newly diagnosed moderate-severe ischemia on stress imaging. For high-risk patients presented with documented AMI and normal epicardial coronary arteries on CCTA or invasive coronary angiography, or nonobstructive CAD, CMR and echocardiography are useful for evaluation of nonischemic cardiomyopathy or myocarditis. Among high risk patients, invasive coronary angiography provides a comprehensive assessment of the extent and severity of obstructive CAD. The determination of the severity of anatomic CAD is critical to guide the use of coronary revascularization. Approximately 6% to 15% of troponin-positive ACS occurs in the absence of obstructive CAD. Additional testing may be helpful to determine the strategy of treatment. Evidence supports that CMR can identify wall motion abnormalities and myocardial edema and distinguish infarct-related scar from non-CAD causes such as myocarditis and nonischemic cardiomyopathy. Performing CMR within 2 weeks of ACS, can be useful to identify MI with nonobstructive CAD (MINOCA) from other causes. The term obstructive CAD indicates CAD with ≥50% stenosis. Nonobstructive CAD is used if CAD <50% stenosis. High risk CAD is defined in the presence of obstructive stenosis with left main stenosis ≥50% or anatomically significant 3-vessel disease (≥70% stenosis).
Indications
Common indications of coronary angiography in high risk ACS patients include:
- New ischemic changes on the ECG
- Troponin-confirmed acute myocardial injury
- New-onset left ventricular systolic dysfunction (ejection fraction <40%)
- Newly diagnosed moderate-severe ischemia on stress imaging
- For high-risk patients presented with documented AMI and normal epicardial coronary arteries on CCTA or invasive coronary angiography, or nonobstructive CAD, CMR and echocardiography are useful for evaluation of nonischemic cardiomyopathy or myocarditis.
- Among high risk patients, invasive coronary angiography provides a comprehensive assessment of the extent and severity of obstructive CAD.
- The determination of the severity of anatomic CAD is critical to guide the use of coronary revascularization.
- Approximately 6% to 15% of troponin-positive ACS occurs in the absence of obstructive CAD.
- Additional testing may be helpful to determine the strategy of treatment.
- Evidence supports that CMR can identify wall motion abnormalities and myocardial edema and distinguish infarct-related scar from non-CAD causes such as myocarditis and nonischemic cardiomyopathy.
- Performing CMR within 2 weeks of ACS, can be useful to identify MI with nonobstructive CAD (MINOCA) from other causes.
- The term obstructive CAD indicates CAD with ≥50% stenosis.
- Nonobstructive CAD is used if CAD <50% stenosis.
- High risk CAD is defined in the presence of obstructive stenosis with left main stenosis ≥50% or anatomically significant 3-vessel disease (≥70% stenosis.