From the Guidelines
Coronary angiography is indicated as a Class I recommendation for patients with non-ST-elevation acute coronary syndromes (NSTE-ACS) who have refractory angina or hemodynamic or electrical instability, as well as those with an elevated risk for clinical events, according to the 2014 AHA/ACC guideline 1. This recommendation is based on the highest level of evidence available, which suggests that an urgent or early invasive strategy, including diagnostic angiography with intent to perform revascularization if appropriate, is beneficial in these patient populations. Key indications for coronary angiography in the context of OMT include:
- Refractory angina, which is defined as persistent chest pain that is not relieved by rest or medication
- Hemodynamic instability, such as hypotension or cardiogenic shock
- Electrical instability, such as ventricular arrhythmias
- Elevated risk for clinical events, as determined by factors such as troponin elevation, ST-segment changes, or other high-risk features. The goal of coronary angiography in these patients is to identify coronary lesions that may be amenable to revascularization, which can improve symptoms, reduce morbidity and mortality, and enhance quality of life 1.
From the Research
Class 1 Indication for Coronary Angiography
- A class 1 indication for coronary angiography is defined as a condition where the procedure is considered to be of greatest benefit to the patient, and the evidence supports its use 2, 3, 4.
Indications for Coronary Angiography
- High-risk patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) without contraindications are considered for prompt invasive coronary angiography and percutaneous or surgical revascularization within 24 to 48 hours 3.
- Patients with unstable angina or non-ST-segment elevation myocardial infarction (NSTEMI) who have high-risk features, such as significant ST-segment depression or elevated troponin levels, are considered for coronary angiography 4.
- Coronary angiography is also recommended for patients with ACS who have recurrent ischemic events despite optimal medical therapy 2, 4.
Timing of Coronary Angiography
- The optimal timing of coronary angiography in patients with NSTE-ACS is still a matter of debate, with some studies suggesting that an acute approach (<2 hours) may not be superior to a subacute approach (<72 hours) 5.
- However, other studies have shown that an invasive strategy involving early coronary angiography with immediate evaluation for revascularization and optimal medical therapy may be beneficial in reducing composite events and improving event-free survival in older patients with NSTE-ACS 6.