Chronic stable angina coronary angiography

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [4] Phone:617-632-7753; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [5]; Smita Kohli, M.D.; Lakshmi Gopalakrishnan, M.B.B.S.

Overview

Coronary angiography is a gold standard test in the evaluation of severity of coronary artery disease and the possibility for revascularization. Coronary angiography is indicated in patients with a high pretest probability of CAD and in symptomatic patients with inconclusive initial noninvasive tests. Provocative testing with ergonovine during angiography may be useful in patients with vasospastic angina. Major complications such as death, MI and stroke associated with routine angiography is as low as 0.1% - 0.2% .

Pretest probability

• When the probability of severe angina is low, noninvasive tests are more appropriate.

• When the pretest probability is high, direct referral for coronary angiography is a suitable choice.

Indications

• The principal indication for coronary angiography in patients with stable angina pectoris with or without previous myocardial infarction is the consideration of coronary revascularization.

• The demonstration of presence of one or more critical coronary artery stenosis does not necessarily indicate that they are the cause of a chest pain syndrome. Furthermore, typical angina pectoris can occur in the absence of obstructive atherosclerotic CAD, thus raising the question of the presence of vasospastic angina, the metabolic syndrome X, or non ischemic causes of chest pain.

• In patients with vasospastic angina diagnosed by noninvasive studies, coronary angiography is indicated to determine whether there is an underlying fixed coronary artery stenosis present in addition to the spasm. Most cases of Prinzmetal's angina occur superimposed upon underlying atherosclerotic plaque.

• The indications for coronary angiography in patients with walk through angina, mixed angina, and postprandial angina are similar to those in patients with chronic stable exertional angina.

• Coronary angiography is most useful in the following clinical scenarios:

• To exclude anatomical abnormalities in young patients as the cause of angina.
• If there is a failure to make a definitive diagnosis after noninvasive tests
• In patients with suspected coronary artery spasm who require provocative tests such as ergonovine
• Sudden cardiac death survivors
• Patient with medical conditions that limit or prevent performance of noninvasive tests.
• An increased probability of left main coronary artery stenosis or multi vessel disease.
• An occupational requirement to confirm or reject a diagnosis of coronary artery disease (e.g. airline pilots).

• Occasionally, coronary angiography is recommended for diagnostic purposes because the patient’s clinical presentation and noninvasive test results are inconclusive.

Diagnostic criteria

• In general, a stenosis of 50% or more of the luminal diameter, which corresponds to a reduction of 70% or more of the cross sectional area, is considered significant coronary artery disease (CAD), since stenosis of this severity reduces coronary blood flow with exercise even though more severe stenosis are required to reduce flow at rest.

• A 70% stenosis of luminal diameter corresponds to a 90% cross-sectional area stenosis, and may result in angina at rest.

• The extent of coronary artery disease (CAD) is often expressed in terms of the number of major epicardial coronary arteries with ≥50% diameter stenosis.

ACC / AHA Guidelines- Coronary Angiography (DO NOT EDIT)

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Class I 1. Patients with known or possible angina pectoris who have survived sudden cardiac death. (Level of Evidence: B) Class IIa 1. Patients with an uncertain diagnosis after noninvasive testing in whom the benefit of a more certain diagnosis outweighs the risk and cost of coronary angiography. (Level of Evidence: C) 2. Patients who cannot undergo noninvasive testing due to disability, illness, or morbid obesity. (Level of Evidence: C) 3. Patients with an occupational requirement for a definitive diagnosis. (Level of Evidence: C) 4. Patients who by virtue of young age at onset of symptoms, noninvasive imaging, or other clinical parameters are suspected of having a nonatherosclerotic cause of myocardial ischemia (coronary artery anomaly, Kawasaki disease, primary coronary artery dissection, radiation-induced vasculoplasty). (Level of Evidence: C) 5. Patients in whom coronary artery spasm is suspected and provocative testing may be necessary. (Level of Evidence: C) 6. Patients with a high pretest probability of left main or 3-vessel CAD. (Level of Evidence: C) Class IIb 1. Patients with recurrent hospitalization for chest pain in whom a definite diagnosis is judged necessary. (Level of Evidence: C) 2. Patients with an overriding desire for a definitive diagnosis and a greater-than-low probability of CAD. (Level of Evidence: C) Class III 1. Patients with significant comorbidity in whom the risk of coronary arteriography outweighs the benefit of the procedure. (Level of Evidence: C) 2. Patients with an overriding personal desire for a definitive diagnosis and a low probability of CAD. (Level of Evidence: C)

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ESC Guidelines- Coronary arteriography for the purposes of establishing a diagnosis in stable angina (DO NOT EDIT)

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Class I 1. Severe stable angina (Class 3 or greater of Canadian Cardiovascular Society Classification), with a high pre-test probability of disease, particularly if the symptoms are inadequately responding to medical treatment. (Level of Evidence: B) 2. Survivors of cardiac arrest. (Level of Evidence: B) 3. Patients with serious ventricular arrhythmias. (Level of Evidence: C) 4. Patients previously treated by myocardial revascularization (PCI, CABG) who develop early recurrence of moderate or severe angina pectoris. (Level of Evidence: C) Class IIa 1. Patients with an inconclusive diagnosis on non-invasive testing, or conflicting results from different noninvasive modalities at intermediate to high risk of coronary artery disease. (Level of Evidence: C) 2. Patients with a high risk of restenosis after PCI if PCI has been performed in a prognostically important site. (Level of Evidence: C)

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Vote on and Suggest Revisions to the Current Guidelines

• The Chronic Stable Angina Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Sources

• The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina

• Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology

• TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina

• The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina