coronary angiography
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Introduction
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
- unstable angina
- ongoing or refractory angina on maximal therapy
- need for intra-aortic balloon counterpulsation
- recurrent chest pain at rest or with minimal activity
- angina pectoris associated with:
- wide-spread ST segment abnormalities
- previous coronary artery revascularization procedure
- myocardial infarction
- residual or recurrent myocardial ischemia
- sustained of symptomatic ventricular tachycardia
- cardiopulmonary arrest & neurologically intact
- pulmonary edema with preserved left ventricular function
- small myocardial infarction with wide-spread ST segment abnormalities on exercise tolerance testing
- myocardial ischemia at low workload (< 5 METS)
- stable angina pectoris or myocardial ischemia with:
- LV dysfunction
- NYHA class 3 or class 4 angina, despite therapy
- positive cardiac stress test
- high probability of left main coronary artery or 3-vessel disease or other severe ischemic heart disease[5]
- uncertain diagnosis after cardiac stress test
- survivors of sudden cardiac death
- suspected coronary vasospasm (Prinzmetal's angina)
- unacceptable symptoms despite optimal medical therapy[5]
- patients with high likelihood of ischemic heart disease unable to undergo undergo diagnostic stress testing in whom findings would affect therapy[5]
- chest pain in a pilot, bus driver or comparable profession suspected to be of cardiac origin
- new-onset LV dysfunction
- in the setting of a condition that may predispose to silent ischemia[2]
- LVEF < 40% associated with symptoms consistent with myocardial ischemia
- TIMI risk score > 2
- positive markers of myocardial infarction
- appropriate use criteria not considered broadly reliable[7]
Contraindications
- uncontrolled ventricular irritability
- increased risk of ventricular tachycardia/fibrillation during catheterization
- uncorrected hypokalemia
- digitalis toxicity
- uncorrected hypertension
- predisposes to myocardial ischemia &/or heart failure during angiography
- febrile illness
- decompensated heart failure
- especially with pulmonary edema
- catheterization may be done with patient sitting up
- anticoagulation with PT > 18 sec
- severe allergy to radiographic contrast agent
- severe renal insufficiency &/or anuria
- dialysis to remove fluid & contrast post catherization
- 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]
More general terms
More specific terms
Additional terms
References
- ↑ nlmpubs.nlm.nih.gov/hstat/ahcpr/
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 16, 17, American College of Physicians, Philadelphia 1998, 2006, 2012, 2015
- ↑ Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 1247
- ↑ 4.0 4.1 Patel MR et al Low Diagnostic Yield of Elective Coronary Angiography N Engl J Med 2010, 362:886-895 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/20220183 <Internet> http://content.nejm.org/cgi/content/short/362/10/886
- ↑ 5.0 5.1 5.2 5.3 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;() <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25070666 <Internet> http://content.onlinejacc.org/article.aspx?articleID=1891717
- ↑ 6.0 6.1 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 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25176289 <Internet> 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 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25176288 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMe1410336 - ↑ 7.0 7.1 Mohareb MM et al Validation of the Appropriate Use Criteria for Coronary Angiography: A Cohort Study. Ann Intern Med. Published online 10 March 2015 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25751586 <Internet> 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 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25751687 <Internet> http://annals.org/article.aspx?articleid=2194948 - ↑ 8.0 8.1 8.2 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: https://www.ncbi.nlm.nih.gov/pubmed/29023926 https://www.medscape.com/viewarticle/892230
- ↑ 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