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coronary angiography

A test in which a contrast medium is injected into the coronary arteries in order to determine coronary artery anatomy, including the presence, severity, & location of any obstruction. Indications: 1) unstable angina a) *ongoing or refractory angina on maximal therapy b) *need for intra-aortic balloon counterpulsation c) *recurrent chest pain at rest or with minimal activity d) *angina pectoris associated with: 1] *congestive heart failure 2] *mitral regurgitation 3] *hypotension e) *wide-spread ST segment abnormalities f) *previous coronary artery revascularization procedure 2) myocardial infarction a) *residual or recurrent myocardial ischemia b) *sustained of symptomatic ventricular tachycardia c) *cardiopulmonary arrest & neurologically intact d) *pulmonary edema with preserved left ventricular function e) *small myocardial infarction with wide-spread ST segment abnormalities on exercise tolerance testing 3) myocardial ischemia at low workload (< 5 METS) 4) *stable angina pectoris or myocardial ischemia with: a) *LV dysfunction b) *NYHA class 3 or class 4 angina, despite therapy c) *positive cardiac stress test d) *high probability of left main coronary artery or 3-vessel disease or other severe ischemic heart disease [5] e) *uncertain diagnosis after cardiac stress test f) survivors of sudden cardiac death g) suspected coronary vasospasm (Prinzmetal's angina) h) *unacceptable symptoms despite optimal medical therapy [5] i) *patients with high likelihood of ischemic heart disease unable to undergo undergo diagnostic stress testing in whom findings would affect therapy [5] 5) *chest pain in a pilot, bus driver or comparable profession suspected to be of cardiac origin 6) new-onset LV dysfunction a) in the setting of a condition that may predispose to silent ischemia [2] - *diabetes mellitus b) LVEF < 40% associated with symptoms consistent with myocardial ischemia 7) TIMI risk score > 2 8) positive markers of myocardial infarction 9) appropriate use criteria not considered broadly reliable [7] Contraindications: 1) uncontrolled ventricular irritability - increased risk of ventricular tachycardia/fibrillation during catheterization 2) uncorrected hypokalemia 3) digitalis toxicity 4) uncorrected hypertension - predisposes to myocardial ischemia &/or heart failure during angiography 5) febrile illness 6) decompensated heart failure a) especially with pulmonary edema b) catheterization may be done with patient sitting up 7) anticoagulation with PT > 18 sec 8) severe allergy to radiographic contrast agent 9) severe renal insufficiency &/or anuria - dialysis to remove fluid & contrast post catherization 10) chronic stable angina with well-controlled symptoms [2] Clinical significance: - provides anatomic diagnosis of presence & severity of CAD - identifies obstructive CAD in ~ 40% of patients with a positive non-invasive stress test [4] - percutaneous revascularization (PCI) can be performed after the diagnostic study [2] Complications: - risks of intra-arterial catheter - local inflammation at the site of catheter insertion - catheter-related infection - hemorrhage [2] - pseudoaneurysm or arteriovenous fistula at the site of catheter insertion [2] - duplex ultrasound to distinguish - contrast nephropathy - cholesterol embolization (eosinophilia) - radiation exposure - iodine contrast may increase risk of hyperthyroidism [8]* * baseline incidence of subclinical hyperthyroidism in patients with ischemic heart disease undergoing coronary angiography high (7.2%) increased to 10% with iodine contrast [8] Notes: - fractional flow reserve measurement during coronary angiography is superior to angiography alone for guiding percutaneous coronary intervention (PCI) in patients with severe but stable coronary artery disease [6]

Related

coronary artery bypass grafting (CABG) percutaneous coronary intervention (PCI)

Specific

cardiac computed tomography angiography; coronary computed tomography angiography; CT angiography (CCTA)

General

cineangiography cardiac catheterization arteriography

References

  1. nlmpubs.nlm.nih.gov/hstat/ahcpr/
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 16, 17, American College of Physicians, Philadelphia 1998, 2006, 2012, 2015
  3. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 1247
  4. Patel MR et al Low Diagnostic Yield of Elective Coronary Angiography N Engl J Med 2010, 362:886-895 PMID: 20220183 http://content.nejm.org/cgi/content/short/362/10/886
  5. Fihn SD et al 2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart DiseaseA Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2014;() PMID: 25070666 http://content.onlinejacc.org/article.aspx?articleID=1891717
  6. Herrmann HC FFR-Guided PCI Beats Optimal Medical Therapy for Severe Stable CAD NEJM Journal Watch. Sept 4, 2014 Massachusetts Medical Society (subscription needed) http://www.jwatch.org - De Bruyne B et al. Fractional flow reserve-guided PCI for stable coronary artery disease. N Engl J Med 2014 Sep 1 PMID: 25176289 http://www.nejm.org/doi/full/10.1056/NEJMoa1408758 - Rade JJ. FFR-guided PCI - FAME may not be so fleeting after all. N Engl J Med 2014 Sep 1 PMID: 25176288 http://www.nejm.org/doi/full/10.1056/NEJMe1410336
  7. Mohareb MM et al Validation of the Appropriate Use Criteria for Coronary Angiography: A Cohort Study. Ann Intern Med. Published online 10 March 2015 PMID: 25751586 http://annals.org/article.aspx?articleid=2194947 - Doll JA, Patel MR Self-Regulation in the Era of Big Data: Appropriate Use of Appropriate Use Criteria Ann Intern Med. Published online 10 March 2015 PMID: 25751687 http://annals.org/article.aspx?articleid=2194948
  8. Bonelli N, Rossetto R, Castagno D Hyperthyroidism in patients with ischaemic heart disease after iodine load induced by coronary angiography: Long-term follow- up and influence of baseline thyroid functional status. Clin Endocrinol (Oxf). 2018 Feb;88(2):272-278. Epub 2017 Nov 20. PMID: 29023926 https://www.medscape.com/viewarticle/892230
  9. JN Learning (Video) Angiography of the Left Main Coronary Artery JAMA Cardiology Published Online: June 28, 2023 https://edhub.ama-assn.org/jn-learning/video-player/18795091