What are the indications for cardiac catheterization to evaluate coronary arteries?

Indications for Cardiac Catheterization to Evaluate Coronary Arteries

Cardiac catheterization for coronary artery evaluation is indicated primarily for patients with suspected coronary artery disease when noninvasive testing is inconclusive or when there is a discrepancy between clinical findings and noninvasive test results.

Primary Indications

Class I Indications (Strongly Recommended)

• Unstable symptoms including:

  • Unstable or progressive classic angina including angina at rest (ICCS functional class IV) 1
  • Acute coronary syndromes (unstable angina, NSTEMI, STEMI) in high-risk patients 2

• Assessment of coronary anatomy when:

  • Preparing for valve replacement surgery in patients at risk for CAD 1
  • Evaluating patients being assessed for cardiac transplantation 1
  • Surveillance of graft vasculopathy after cardiac transplantation 1
  • Evaluating coronary circulation in pulmonary atresia with intact septum 1

• Hemodynamic assessment when:

  • Noninvasive tests are inconclusive or discrepant with clinical findings regarding severity of coronary or valvular disease 1
  • Assessing intermediate coronary stenoses (30-70% luminal narrowing) in patients with anginal symptoms 1

Class IIa Indications (Reasonable to Perform)

• Assessment of coronary circulation in Kawasaki disease with suspected coronary involvement 1
• Evaluation of suspected congenital coronary artery anomalies 1
• Assessment of anatomy and hemodynamics in postoperative cardiac patients with unexpectedly complicated course when noninvasive imaging is inconclusive 1
• Evaluation of patients with cardiomyopathy or myocarditis 1

Special Considerations

Physiologic Assessment During Catheterization

Physiologic measurements during catheterization provide valuable information for:

• Determining significance of intermediate stenoses using:

  • Fractional Flow Reserve (FFR)
  • Coronary flow velocity measurements
  • Coronary pressure measurements 1

• Evaluating patients with anginal symptoms without an apparent angiographic culprit lesion 1

Contraindications and Cautions

Relative contraindications for ambulatory cardiac catheterization include:

• Unstable symptoms or clinical features suggesting higher risk for complications
• NYHA functional class III or IV heart failure
• Acute myocardial infarction within 5 days
• Pulmonary edema due to myocardial ischemia
• Uncontrolled hypertension
• Severe peripheral vascular disease 1

Evolving Approaches

Recent evidence suggests a shift toward coronary CT angiography (CTA) as a first-line test for many patients with stable chest pain:

• European and UK guidelines now recommend coronary CTA as the preferred initial test in patients with lower ranges of clinical likelihood of CAD 1
• CTA-first strategy does not increase rates of invasive catheterization or revascularization 1
• Patients with knowledge of coronary plaque from CTA are more likely to implement preventive therapies 1

Procedural Considerations

• For patients on dual antiplatelet therapy (DAPT), guidelines recommend continuing therapy during diagnostic catheterization, especially in patients with recent stent placement 3
• Radial approach is preferred when possible to reduce bleeding risk 3
• When performed at specialized centers, cardiac catheterization has a low complication rate (major complications ~1.2%) 4

Common Pitfalls

• Relying solely on angiographic appearance without physiologic assessment can lead to inappropriate interventions for non-significant stenoses
• Routine assessment of angiographic disease severity in patients with positive, unequivocal noninvasive functional studies is not recommended 1
• Failing to consider the patient's overall risk profile when deciding between invasive and non-invasive approaches
• Overlooking the potential of coronary CTA as a first-line diagnostic tool for stable patients

Cardiac catheterization remains an essential diagnostic tool when used appropriately, but its use should be guided by clinical presentation, risk factors, and results of non-invasive testing to maximize benefit while minimizing risk.