Related Experiment Video
Updated: Apr 28, 2026
Interventional Diagnostic Procedure: A Practical Guide for the Assessment of Coronary Vascular Function
Published on: March 15, 2022
Symptoms and angiographic findings of patients undergoing elective coronary angiography without prior stress testing
Mouin S Abdallah1, John A Spertus1, Brahmajee K Nallamothu2
1University of Missouri-Kansas City, Kansas City, Missouri; Saint Luke's Mid America Heart Institute, Kansas City, Missouri.
Insights
Many patients skip preprocedural stress testing before elective coronary angiography. This approach was not driven by severe angina and did not increase obstructive coronary artery disease detection rates.
Area of Science:
- Cardiology
- Clinical Medicine
- Health Services Research
Background:
- Many patients undergo elective coronary angiography without preprocedural stress testing.
- The appropriateness of this strategy is debated, particularly concerning symptom severity and diagnostic yield.
Purpose of the Study:
- To assess differences in angina severity and obstructive coronary artery disease (CAD) detection between patients with and without preprocedural stress testing before elective coronary angiography.
- To stratify findings based on prior CAD history.
Main Methods:
- Analysis of data from the National Cardiovascular Data Registry CathPCI Registry (July 2009-April 2013).
- Comparison of patients undergoing elective coronary angiography, stratified by the presence or absence of preprocedural stress testing and prior CAD history.
- Assessment of angina (Canadian Cardiovascular Society [CCS] class) and obstructive CAD rates. Standardized difference (SD) >10% considered clinically meaningful.
Main Results:
- Approximately 40% of patients lacked preprocedural stress testing.
- Patients without prior CAD history and no stress test were more often angina-free (CCS class 0) but had similar obstructive CAD rates compared to those with stress testing.
- Patients with prior CAD history and no stress test reported more severe angina (CCS class III/IV) but similar rates of obstructive CAD compared to those with stress testing.
Conclusions:
- A significant proportion of patients undergoing elective coronary angiography do not receive preprocedural risk stratification via stress testing.
- The decision to proceed to angiography without stress testing in these patients was not primarily linked to severe angina symptoms.
- This practice did not lead to a higher detection rate of obstructive coronary artery disease.
Abstract:
Many patients undergo elective coronary angiography without preprocedural stress testing that may be suitable if performed in patients with more angina pectoris or more frequently identified obstructive coronary artery disease (CAD). Patients in the National Cardiovascular Data Registry CathPCI Registry undergoing elective coronary angiography from July 2009 to April 2013 were assessed for differences in angina (Canadian Cardiovascular Society [CCS] class) and severity of obstructive CAD in those with and without preprocedural stress testing, stratified by CAD history. Given the large sample size, differences were considered clinically meaningful if the standardized difference (SD) was >10%. Of 790,601 patients without CAD history, 36.9% did not undergo preprocedural stress testing. Compared with patients with preprocedural stress testing, patients without preprocedural stress testing were more frequently angina free (CCS class 0; 28.2% with stress test vs 38.5% without, SD = 14.8%) and had similar rates of obstructive CAD (40.1% with stress test vs 35.7% without, SD = 9.0). Of 449,579 patients with CAD history, 44.2% did not undergo preprocedural stress testing. Patients without preprocedural stress testing reported more angina (CCS class III/IV angina: 17.8% vs 13.4%; SD = 11.3%) but were not more likely to have obstructive CAD (78.7% vs 81.1%; SD = 5.8%) than patients with preprocedural stress testing. In conclusion, approximately 40% of patients undergoing elective coronary angiography did not have preprocedural risk stratification with stress testing. For these patients, the clinical decision to proceed directly to invasive evaluation was not driven primarily by severe angina and did not result in higher detection rates for obstructive CAD.
Related Concept Videos
01:29Angina III: Clinical Manifestations and Assessment
01:30Acute Coronary Syndrome III: Diagnostic Studies
01:17Imaging Studies for Cardiovascular System I:Echocardiography
Indications: Echocardiography is utilized to diagnose heart failure, valve disorders, and myocardial infarction. It also assesses cardiac structures' size, shape, and motion,...
01:19Acute Coronary Syndrome II: Pathophysiology and Clinical Manifestations
01:27Coronary Artery Disease V: Interprofessional Care
01:28Cardiac Catheterization I: Pre-Procedure Overview