From the Guidelines
Clinical predictors of high-risk coronary anatomy in patients undergoing coronary angiography are best identified by advanced age, male gender, diabetes mellitus, prior myocardial infarction, typical angina symptoms, and multiple cardiovascular risk factors, as outlined in the 2019 ESC guidelines for the diagnosis and management of chronic coronary syndromes 1. The strongest predictors of high-risk coronary anatomy include:
- Advanced age (particularly over 65)
- Male gender
- Diabetes mellitus
- Prior myocardial infarction
- Typical angina symptoms
- Multiple cardiovascular risk factors such as hypertension, hyperlipidemia, and smoking history Specific clinical markers like elevated troponin levels, ST-segment changes on ECG (particularly ST depression or T-wave inversions), reduced left ventricular ejection fraction (<40%), and a high pre-test probability score (such as TIMI, GRACE, or Diamond-Forrester) are also significant predictors 1. Patients with chronic kidney disease, peripheral arterial disease, or cerebrovascular disease demonstrate higher likelihood of severe coronary disease due to the systemic nature of atherosclerosis, as noted in the 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease 1. The presence of multiple risk factors substantially increases the probability of finding high-risk coronary anatomy, including left main disease, three-vessel disease, or proximal left anterior descending artery stenosis, highlighting the importance of careful patient selection for coronary angiography 1. These predictors are valuable for risk stratification before invasive procedures and help guide appropriate patient selection for coronary angiography, ensuring those most likely to benefit from revascularization are identified efficiently, as emphasized in the 2019 ESC guidelines 1.
From the Research
Clinical Predictors of High-Risk Coronary Anatomy
- The presence of peripheral vascular disease and a GRACE score of >140 are strong predictors of high-risk coronary anatomy (HRCA) in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) undergoing early angiography 2.
- Clinical characteristics such as female gender, atypical ischemic symptoms, and the absence of traditional cardiac risk factors are associated with a higher frequency of normal cardiac catheterizations 3.
- The traditional age, sex, and angina typicality-based approach for estimating pretest probability of angiographically significant coronary artery disease may overestimate the actual prevalence of disease in patients undergoing coronary computed tomographic angiography 4.
- Diabetes is associated with increased risk of acute myocardial infarction (AMI) and higher risk of death in patients hospitalized with AMI, highlighting the need for adherence to evidence-based therapies in this high-risk population 5.
- Patient characteristics, such as younger age, female sex, and atypical chest pain, are independent factors associated with nonobstructive coronary artery disease (CAD) in patients undergoing elective angiography 6.
Predictors of High-Risk Coronary Anatomy
- Peripheral vascular disease (OR = 1.88,95% CI = 1.62-5.80, P < 0.001) 2
- GRACE score of >140 (OR = 1.88,95% CI = 1.29-2.75, P < 0.001) 2
- Female gender (odds ratio 3.55,95% CI 2.93-4.28) 3
- Atypical ischemic symptoms or no symptoms 3
- Absence of diabetes, hyperlipidemia, smoking history, and peripheral vascular disease 3
Outcomes in Patients with High-Risk Coronary Anatomy
- Patients with HRCA are prone to more complications during hospitalization and at 30 days (11.9% vs. 6%, P < 0.01) and increased 1-year mortality (6.7% vs. 0.9%, P < 0.001) 2.
- HRCA is the strongest predictor for 30-day major adverse cardiac and cerebrovascular events (MACCE) (OR = 2.32,95% CI = 1.42-3.79, P < 0.001) 2.
- Diabetes is associated with a 52% higher hazard of all-cause 1-year mortality (hazard ratio, 1.52 [95% CI, 1.23-1.89]) in patients hospitalized with AMI 5.