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The utility of a 'non-significant' coronary angiogram
T K M Wang1, T H T Oh1, C B Samaranayake1
1Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand.
Insights
Patients with chest pain and mild coronary artery disease (CAD) found via coronary angiography often do not receive significant management changes. This study suggests invasive angiography may not provide the reassurance expected in these non-obstructive CAD cases.
Area of Science:
- Cardiology
- Internal Medicine
- Diagnostic Imaging
Background:
- Coronary angiography is the gold standard for diagnosing coronary artery disease (CAD).
- A significant number of patients with chest pain exhibit non-obstructive CAD (<50% stenosis) on angiography.
- The clinical impact of non-significant findings on patient management and outcomes remains unclear.
Purpose of the Study:
- To review the characteristics and outcomes of patients referred for chest pain who had mild or absent CAD on coronary angiography.
- To evaluate the influence of non-significant coronary angiography results on medical management and clinical events.
Main Methods:
- A retrospective review of 2983 patients undergoing coronary angiography between July 2010 and October 2011.
- Identification of 366 patients (12.3%) with absent or mild CAD evaluated for chest pain.
- Follow-up of these patients for an average of 2.3 years to assess outcomes.
Main Results:
- The cohort comprised 366 patients (mean age 60.0 years, 56.1% female) with non-obstructive CAD.
- Abnormal ECGs (55.0%) and positive stress tests (57.7% of those tested) were common.
- Following angiography, 43.2% had no medication changes, while 14.2-22.1% initiated new cardiac medications. Major adverse cardiovascular events and 1-year readmissions for chest pain were low (1.9% and 6.0%, respectively).
Conclusions:
- Even non-obstructive coronary artery disease may warrant medical therapy to slow progression.
- Invasive coronary angiography in patients with non-obstructive CAD may not consistently provide the expected patient and physician reassurance.
- Further research is needed to optimize the management and interpretation of findings in this patient group.
Background:
Coronary angiography is the gold standard for assessing coronary artery disease (CAD). In many patients with chest pain, no or mild CAD (< 50% stenosis) is found. It is uncertain whether this 'non-significant' result influences management and outcomes. We reviewed characteristics and outcomes in a contemporary cohort of chest pain referrals who had mild or absent CAD on coronary angiography.
Method:
All patients undergoing coronary angiography at Auckland City Hospital during July 2010-October 2011 were reviewed (n = 2983). Of these, 12.3% (n = 366) underwent coronary angiography for evaluation of chest pain and were found to have absent or mild CAD. These patients were followed up for 2.3 ± 0.6 years.
Results:
Mean age was 60.0 ± 12.3 years, 56.1% were female. The ECG was abnormal in 55.0% of patients. Stress testing for inducible ischaemia was undertaken in 40.7% of patients and was abnormal in 57.7%. Following angiography, 43.2% had no changes to cardiac medications. Additional drug therapy (aspirin, statin, beta-blockers, ACE-inhibitor) was commenced in around 14.2-22.1% of cases. These drugs were discontinued in 4.1-8.2% of patients. Rates of major adverse cardiovascular events and readmissions with chest pain were 0.3% (1) and 1.9% (7) respectively at 30 days, and 1.9% (7) and 6.0% (22) at 1 year.
Conclusion:
Although even non-obstructive atheroma may justify medical therapy to limit disease progression, our findings may suggest that in these cases, invasive coronary angiography, may not lead to the patient/physician reassurance justified by historical data.
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