Does this patient with coronary artery disease and persistent chest pain require an additional catheterization?

Catheterization Decision for Patients with Coronary Artery Disease and Persistent Chest Pain

For patients with coronary artery disease and persistent chest pain despite optimal guideline-directed medical therapy, invasive coronary angiography is recommended, especially if they have high-risk features such as significant left main, proximal left anterior descending stenosis, or multivessel disease. 1

Assessment Algorithm for Catheterization Decision

Step 1: Evaluate Clinical Risk and Symptom Status

• High-risk features requiring immediate catheterization:
  • Worsening frequency of symptoms (daily/weekly angina)
  • Known significant left main disease (≥50% stenosis)
  • Known proximal left anterior descending stenosis
  • Known multivessel coronary artery disease
  • History of prior coronary revascularization with recurrent symptoms
  • Refractory angina despite optimal medical therapy

Step 2: Review Prior Testing Results

• Prior anatomic testing (CCTA or previous catheterization):

  • If obstructive CAD (≥50% stenosis) with persistent symptoms → proceed to catheterization
  • If stenosis of 40-90% in proximal or middle segments → consider FFR-CT first if available
  • If prior moderate-severely abnormal stress test without interval coronary angiography → proceed to catheterization

• Prior functional testing:

  • If moderate-severe ischemia on stress testing → proceed to catheterization
  • If FFR-CT <0.8 → proceed to catheterization

Step 3: Optimize Medical Therapy

• Ensure patient is on optimal guideline-directed medical therapy (GDMT) before proceeding with catheterization
• However, for high-risk features listed above, do not delay catheterization for medication optimization

Evidence-Based Rationale

The 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guidelines provide clear recommendations for patients with known CAD and persistent chest pain 1:

1. For patients with obstructive CAD who have stable chest pain despite GDMT and moderate-severe ischemia, invasive coronary angiography is recommended (Class 1, Level A)

2. For patients with worsening frequency of symptoms with significant left main, proximal LAD stenosis, or multivessel CAD on prior anatomic testing or history of prior coronary revascularization, invasive coronary angiography is recommended (Class 1, Level A)

3. For patients with obstructive CAD who have stable chest pain with CCTA-defined ≥50% stenosis in the left main coronary artery, obstructive CAD with FFR-CT ≤0.80, or severe stenosis (≥70%) in all 3 main vessels, invasive coronary angiography is effective for guiding therapeutic decision-making (Class 1, Level B-R)

Important Clinical Considerations

• Stent thrombosis risk: Patients with prior stenting who present with recurrent chest pain should be evaluated promptly with catheterization, as stent thrombosis can occur in approximately 1% of patients despite antiplatelet therapy and carries a mortality rate up to 45% 2

• Non-obstructive CAD: For patients with known non-obstructive CAD (<50% stenosis), CCTA can be useful to determine progression of atherosclerotic plaque before considering catheterization (Class 2a, Level B-NR) 1

• Intermediate stenosis: For patients with coronary artery stenosis of 40% to 90% in a proximal or middle segment, FFR-CT is reasonable for diagnosis of vessel-specific ischemia before proceeding to invasive catheterization (Class 2a, Level B-NR) 1

• Caveat: Avoid catheterization in patients with extensive comorbidities where risks likely outweigh benefits, or in patients who will not consent to revascularization regardless of findings

By following this evidence-based approach, you can determine which patients with coronary artery disease and persistent chest pain will benefit most from additional catheterization, optimizing outcomes related to morbidity, mortality, and quality of life.