Chronic stable angina coronary angiography

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Chronic Stable Angina
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Walk through Angina
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Vasospastic Angina

Differentiating Chronic Stable Angina from Acute Coronary Syndromes

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; 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%.[1]

Coronary Angiography

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 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.
  • 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.

2014 ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT)[2][3]

DIAGNOSIS OF SIHD

Invasive Testing for Diagnosis of Coronary Artery Disease in Patients With Suspected SIHD(DO NOT EDIT)[2][3]

Class I
"1. Coronary angiography is useful in patients with presumed SIHD who have unacceptable ischemic symptoms despite

GDMT and who are amenable to, and candidates for, coronary revascularization (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)"
Class IIa
"1. Coronary angiography is reasonable to define the extent and severity of coronary artery disease (CAD) in patients with suspected SIHD whose clinical characteristics and results of noninvasive testing (exclusive of stress testing) indicate a high likelihood of severe IHD and who are amenable to, and candidates for, coronary revascularization. (Level of Evidence: C)"
"2. Coronary angiography is reasonable to define the extent and severity of coronary artery disease (CAD) in patients with suspected SIHD whose clinical characteristics and results of noninvasive testing (exclusive of stress testing) indicate a high likelihood of severe IHD and who are amenable to, and candidates for, coronary revascularization (Level of Evidence: C)"
Class IIb
"1. Coronary angiography might be considered in patients with stress test results of acceptable quality that do not suggest the presence of CAD when clinical suspicion of CAD remains high and there is a high likelihood that the findings will result in important changes to therapy. (Level of Evidence: C)"

ESC Guidelines- Coronary Arteriography for the Purposes of Establishing a Diagnosis in Stable Angina (DO NOT EDIT)[4]

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)"

References

  1. Noto TJ, Johnson LW, Krone R, Weaver WF, Clark DA, Kramer JR et al. (1991) Cardiac catheterization 1990: a report of the Registry of the Society for Cardiac Angiography and Interventions (SCA&I). Cathet Cardiovasc Diagn 24 (2):75-83. PMID: 1742788
  2. 2.0 2.1 Fihn SD, Blankenship JC, Alexander KP, Bittl JA, Byrne JG, Fletcher BJ; et al. (2014). "2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a 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. 64 (18): 1929–49. doi:10.1016/j.jacc.2014.07.017. PMID 25077860.
  3. 3.0 3.1 Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM; et al. (1999). "ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina)". Circulation. 99 (21): 2829–48. PMID 10351980.
  4. Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F; et al. (2006). "Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology". Eur Heart J. 27 (11): 1341–81. doi:10.1093/eurheartj/ehl001. PMID 16735367.

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