When is an angiogram recommended?

When is Coronary Angiography Recommended?

Coronary angiography is primarily recommended for patients with acute coronary syndromes (cardiogenic shock, hemodynamic instability, failed reperfusion), symptomatic coronary disease with high-risk features on noninvasive testing, or when noninvasive imaging is inconclusive or contradictory. 1

Acute Coronary Syndromes - Immediate Angiography Required

Class I indications (must perform):

• Cardiogenic shock or acute severe heart failure developing after initial presentation 1
• Hemodynamic instability with ongoing chest pain and elevated cardiac biomarkers 2
• Evidence of acute thrombotic occlusion 2
• Intermediate- or high-risk findings on predischarge noninvasive ischemia testing 1
• Spontaneous or easily provoked myocardial ischemia during hospitalization 1

Post-Fibrinolytic Therapy Settings

Class IIa indications (reasonable to perform):

• Evidence of failed reperfusion or reocclusion after fibrinolytic therapy—perform as soon as logistically feasible 1
• Stable patients after successful fibrinolysis—ideally between 3-24 hours, but NOT within the first 2-3 hours after fibrinolytic administration 1

Critical pitfall: Performing angiography within 2-3 hours of fibrinolytic therapy increases bleeding risk substantially and should be reserved only for rescue PCI in failed fibrinolysis with significant myocardial jeopardy. 1

Chronic Coronary Syndromes - Risk-Stratified Approach

Proceed directly to angiography when:

• Very high (>85%) clinical likelihood of obstructive disease with severe symptoms refractory to medical therapy 1
• Angina occurring at low levels of exercise with high event risk 1
• De novo symptoms highly suggestive of obstructive CAD at low exercise levels 1

Noninvasive testing first, then angiography if:

• Moderate-to-severe ischemia documented on current or prior stress testing (≤1 year) 2
• Obstructive CAD (≥50% stenosis) identified on coronary CT angiography 2
• Known CAD with angina or significant ischemia, unless revascularization is not feasible 2

Cerebrovascular Disease Evaluation

Class IIa indications:

• When complete carotid arterial occlusion is suggested by duplex ultrasonography, MRA, or CTA in patients with retinal or hemispheric neurological symptoms—angiography may determine if the lumen is sufficiently patent for revascularization 1
• When noninvasive imaging is inconclusive or yields discordant results in patients with transient retinal or hemispheric symptoms 1

Class IIb indication:

• Patients with renal dysfunction to limit radiographic contrast by evaluating a single vascular territory 1

Important caveat: Catheter-based angiography carries a 1% stroke risk when performed by experienced physicians; rates >1% are considered unacceptable. 1 Angiography is increasingly reserved for therapeutic revascularization rather than pure diagnosis. 1

Valvular Heart Disease Pre-Operative Assessment

Class I indication:

• Men ≥40 years, postmenopausal women, and patients with coronary risk factors or suspected CAD undergoing valve surgery should undergo coronary angiography 1

Class III (do not perform):

• Young patients without coronary risk factors, no CAD history, and no ischemia evidence undergoing nonemergency valve surgery 1
• Severely hemodynamically unstable patients before valve surgery 1

When Angiography is NOT Warranted

Avoid angiography in:

• Asymptomatic patients after treatment without high-risk features (elevated troponin, hemodynamic instability, major arrhythmias, dynamic ST changes, diabetes) 3
• Stable patients >24 hours after successful fibrinolysis (Class IIb—uncertain benefit) 1
• Delayed PCI of totally occluded infarct artery >24 hours after STEMI in stable patients (Class III—no benefit) 1

Critical pitfall for diabetic patients: Never assume symptom absence equals low risk—diabetics may have silent ischemia despite significant coronary disease. 3 Troponin elevation, hemodynamic changes, or arrhythmias supersede symptom assessment. 3

Functional Assessment During Angiography

When angiography is performed:

• Radial artery access is the preferred access site 1
• Have coronary pressure assessment (FFR/iFR) available to evaluate functional severity of intermediate non-left main stenoses before revascularization 1
• FFR ≤0.80 or iFR ≤0.89 indicates significant stenosis requiring revascularization 1
• Systematic wire-based assessment of all vessels is NOT recommended 1