Is an angiogram safe for an elderly patient with severe aortic stenosis?

Coronary Angiography in Elderly Patients with Severe Aortic Stenosis

Coronary angiography is safe and routinely indicated in elderly patients with severe aortic stenosis who are being considered for aortic valve replacement, as preoperative assessment of coronary anatomy is essential for procedural planning. 1

Routine Indication for Angiography

• Preoperative coronary angiography should be performed routinely in patients with severe aortic stenosis being evaluated for valve replacement, with the decision determined by age, symptoms, and coronary risk factors. 1
• The procedure is part of standard pre-intervention workup to identify concomitant coronary artery disease that may require simultaneous revascularization. 1
• Cardiac catheterization and angiography are particularly helpful when there is discordance between clinical findings and echocardiography. 1

Safety Considerations in Elderly Patients

While the guidelines establish angiography as routine practice, elderly patients with severe AS require careful hemodynamic management during the procedure:

• Maintain adequate preload during the procedure, as patients with severe AS are preload-dependent and cannot compensate for volume depletion. 2
• Avoid vasodilators and maintain careful blood pressure control during catheterization. 2
• The procedure should be performed in centers with appropriate expertise to minimize complications, particularly in complex or high-risk elderly patients. 1

Clinical Context for Angiography

The angiogram serves multiple critical purposes in elderly AS patients:

• Identifies coronary artery disease requiring CABG, which would favor surgical AVR over TAVR in appropriate candidates. 1
• For patients with concomitant CAD, the SYNTAX score helps define disease complexity and guides whether combined SAVR plus CABG versus TAVR plus PCI is appropriate. 1
• In elderly patients ≥80 years, TAVR is generally preferred over SAVR, but coronary anatomy assessment remains essential for procedural planning. 3

Heart Team Decision-Making

• All decisions regarding intervention in elderly AS patients should involve a multidisciplinary Heart Team comprising cardiac surgery, interventional cardiology, cardiac imaging, anesthesiology, and geriatrics expertise. 1, 2
• The angiogram results are integrated with surgical risk assessment (STS-PROM score), frailty evaluation, and comorbidity burden to determine optimal treatment strategy. 1, 4

Key Pitfall to Avoid

Do not delay angiography due to concerns about procedural risk in elderly patients—the information obtained is essential for appropriate treatment planning, and the risk of the angiogram is substantially lower than the risk of untreated severe symptomatic AS, which carries 50% mortality at one year without intervention. 3