What are the clinical predictors of high-risk coronary artery disease (CAD) in patients undergoing coronary angiography (CA)?

From the Guidelines

Clinical predictors of high-risk coronary anatomy in patients undergoing coronary angiography include advanced age, male gender, diabetes mellitus, hypertension, hyperlipidemia, smoking history, family history of premature coronary artery disease, and prior history of myocardial infarction or revascularization, as identified in the 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline 1. These predictors are crucial in identifying individuals at elevated risk for severe coronary artery disease. Key factors that suggest high-risk anatomy include:

• Typical angina at rest or with minimal exertion
• Positive stress tests with significant ST-segment depression (>2mm)
• Multiple perfusion defects on nuclear imaging
• Wall motion abnormalities on stress echocardiography
• Elevated cardiac biomarkers (troponin, CK-MB) and ECG changes such as ST-segment elevation or depression, T-wave inversions, and Q waves Certain comorbidities like chronic kidney disease, peripheral arterial disease, and cerebrovascular disease further increase the probability of high-risk coronary anatomy, as noted in the 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update 1. These predictors help clinicians identify patients who may benefit from early invasive strategies and more aggressive medical therapy. A simple risk score for predicting severe (left main or 3-vessel) CAD, based on 5 clinical variables: age, sex, history of MI, presence of typical angina, and diabetes mellitus with or without insulin use, can be easily memorized and calculated, yielding an integer ranging from 0 to 10, as described in the 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline 1. This score can be applied to determine if a patient is more suitable for stress testing or possibly for proceeding directly to coronary angiography. For example, a 50-year-old male patient who has diabetes mellitus, is taking insulin, and has typical angina and a history of previous MI has a likelihood of severe coronary stenosis >60% and thus might proceed directly to angiography if deemed necessary by the clinician, as suggested in the 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline 1. The 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update also emphasizes the importance of balancing the risks and benefits of coronary angiography, particularly in patients with advanced age, severe comorbidities, or history of allergic reactions to radiographic contrast material 1. Ultimately, the decision to proceed with coronary angiography should be made on a case-by-case basis, taking into account the individual patient's risk factors, clinical presentation, and potential benefits of the procedure, as recommended in the 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update 1.

From the Research

Clinical Predictors of High-Risk Coronary Anatomy

• The study 2 developed a clinical model to identify patients with high-risk coronary artery disease, which included 9 variables: age, sex, diabetes, hypertension, current smoking, hyperlipidemia, family history of CAD, history of peripheral vascular disease, and chest pain symptoms.
• Patients were divided into 3 risk categories: low (≤7 points), intermediate (8 to 17 points) and high (≥18 points), with those scoring ≥18 points having a high specificity of 99.3% and a positive likelihood ratio of 8.48 for high-risk CAD.
• Diabetes is an established risk factor for adverse cardiovascular outcomes, including mortality, and is associated with an increased mortality risk in patients undergoing coronary angiography, independent of several risk factors including the degree of CAD 3.
• The relationship between diabetes and mortality risk in the presence of extensive or diffuse form of coronary artery disease is controversial, but studies suggest that diabetes may be associated with a higher risk of mortality in patients with CAD 3.

Screening and Risk Assessment

• Current literature indicates that there is a strong correlation between coronary artery disease and type 2 diabetes, with arteriosclerotic progression occurring earlier and to a greater extent in diabetic patients 4.
• Screening for coronary artery disease using CT angiography in high-risk patients with diabetes did not reduce the composite rate of all-cause mortality, nonfatal MI, or unstable angina requiring hospitalization at 4 years 5.
• Less invasive imaging methods than conventional coronary angiography are gradually being used more in the diagnosis of CAD and show high effectiveness 4.
• Possible blood markers as predictors of CAD, mostly related to the lipidemic profile of subjects, can be used to diagnose CAD in an early stage or screen for its presence in asymptomatic diabetic patients 4.

Coronary Angiography and Angioplasty

• Diagnostic and therapeutic cardiac catheterization are important resources for the clinical assessment and management of coronary atherosclerosis in diabetic patients 6.
• Anatomic peculiarities of CAD in diabetics can be well characterized by angiography, associated or not with intravascular ultrasound 6.
• The worse outcome following coronary revascularization procedures, either angioplasty or surgery, in diabetic patients is one of the main fields of clinical research 6.