ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease. Invasive Testing for Diagnosis of Coronary Artery Disease in Patients With Suspected SIHD: Recommendations (New Section)See. Online Data Supplement 1for additional information. Class I1. 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 IIa.
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 (7–1. Level of Evidence: C)2. Coronary angiography is reasonable in patients with suspected symptomatic SIHD who cannot undergo diagnostic stress testing, or have indeterminate or nondiagnostic stress tests, when there is a high likelihood that the findings will result in important changes to therapy. Level of Evidence: C)Class IIb. 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)This section has been added to the 2. SIHD focused update to fill a gap in the 2.
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SIHD guideline (4). It specifically addresses the role of coronary angiography for the diagnosis of CAD in patients with suspected SIHD. Coronary angiography for risk stratification has been addressed in Section 3. SIHD full- text guideline (4). Recommendations for use of coronary angiography in the following specific clinical circumstances have been addressed in other guidelines or statements and will not be discussed further here: • Patients with heart failure and/or reduced ejection fraction (1. Patients who have experienced sudden cardiac death or sustained ventricular arrhythmia (1. Patients undergoing preoperative cardiovascular evaluation for noncardiac surgery (including solid organ transplantation) (1.
Evaluation of cardiac disease among patients who are kidney or liver transplantation candidates (1. Note that ACC/AHA guidelines for coronary angiography were published in 1. There are no high- quality data on which to base recommendations for performing diagnostic coronary angiography because no study has randomized patients with SIHD to either catheterization or no catheterization. Trials in patients with SIHD comparing revascularization and GDMT have, to date, all required angiography, most often after stress testing, as a prerequisite for subsequent revascularization. Additionally, the “incremental benefit” of detecting or excluding CAD by coronary angiography remains to be determined.
The ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) trial is currently randomizing patients with at least moderate ischemia on stress testing to a strategy of optimal medical therapy alone (with coronary angiography reserved for failure of medical therapy) or routine cardiac catheterization followed by revascularization (when appropriate) plus optimal medical therapy. Before randomization, however, patients with normal renal function will undergo “blinded” computed tomography (CT) angiography to exclude them if significant left main CAD or no significant CAD is present. The writing group strongly endorses the ISCHEMIA trial, which will provide contemporary, high- quality evidence about the optimal strategy for managing patients with nonleft main SIHD and moderate- to- severe ischemia. In the majority of patients with suspected SIHD, noninvasive stress testing for diagnosis and risk stratification is the appropriate initial study.
Importantly, coronary angiography is appropriate only when the information derived from the procedure will significantly influence patient management and if the risks and benefits of the procedure have been carefully considered and understood by the patient. Coronary angiography to assess coronary anatomy for revascularization is appropriate only when it is determined beforehand that the patient is amenable to, and a candidate for, percutaneous or surgical revascularization. In patients with abnormal, noninvasive stress testing for whom a diagnosis of CAD remains in doubt, many clinicians proceed to diagnostic coronary angiography. However, in some patients, multidetector CT angiography may be appropriate and safer than routine invasive angiography for this purpose. Indications and contraindications to CT angiography, including subsets of patients for whom it can be considered, are also discussed in the 2. CT angiography (1.
CT (1. 9). Although coronary angiography is considered the “gold standard” for the diagnosis of CAD, it has inherent limitations and shortcomings. Angiographic assessment of stenosis severity relies on comparison to an adjacent, nondiseased reference segment.
In diffusely diseased coronary arteries, lack of a normal reference segment may lead to underestimation of lesion severity by angiography. Multiple studies have documented significant interobserver variability in the grading of coronary artery stenosis (2. Although quantitative coronary angiography provides a more accurate assessment of lesion severity than does visual assessment, it is rarely used in clinical practice because it does not accurately assess the physiological significance of lesions (2. Many stenoses considered to be severe by visual assessment of coronary angiograms (i.
Coronary angiography also cannot assess whether an atherosclerotic plaque is stable or “vulnerable” (i.Intravascular ultrasound and optical coherence tomography provide more precise information about the severity of stenosis and plaque morphology than does coronary angiography and, in certain cases, can be useful adjunctive tests (9). there. These imaging procedures are discussed in the 2.PCI guideline (9).
FFR can assess the hemodynamic significance of angiographically “intermediate” or “indeterminant” lesions and allows one to decide when PCI may be beneficial or safely deferred (2. It has been suggested in several studies that a PCI strategy guided by FFR may be superior to a strategy guided by angiography alone (5,2. Invasive procedures may cause complications. Data from the ACC’s National Cardiovascular Data Registry Cath. PCI Registry during the 2.
Complications in earlier reports included death, stroke, myocardial infarction (MI), bleeding, infection, contrast allergic or anaphylactoid reactions, vascular damage, contrast- induced nephropathy, arrhythmias, and need for emergency revascularization (2. here. Complications are more likely to occur in certain patient groups, including those of advanced age (> 7.Canadian Cardiovascular Society class IV angina or New York Heart Association class IV heart failure), severe left ventricular dysfunction or CAD (particularly left main disease), severe valvular disease, severe comorbid medical conditions (e.The risk of contrast- induced nephropathy is increased in patients with renal insufficiency or diabetes mellitus (9,3.In deciding whether angiography should be performed in these patients, these risks should be balanced against the increased likelihood of finding critical CAD.The concept of informed consent requires that risks and benefits of and alternatives to coronary angiography be explicitly discussed with the patient before the procedure is undertaken.Despite these shortcomings and potential complications, coronary angiography is useful to a) ascertain the cause of chest pain or anginal equivalent symptoms, b) define coronary anatomy in patients with “high- risk” noninvasive stress test findings (Section 3.
CAD may be the cause of depressed left ventricular ejection fraction, d) assess for possible ischemia- mediated ventricular arrhythmia, e) evaluate cardiovascular risk among certain recipient and donor candidates for solid- organ transplantation, and f) assess the suitability for revascularization of patients with unacceptable ischemic symptoms (i.