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Expert opinion regarding indications for coronary angiography before noncardiac surgery
1Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.
Insights
Expert consensus exists for performing coronary angiography based on specific noninvasive cardiac test results indicating significant myocardial ischemia. Limited ischemia or minor abnormalities do not warrant routine catheterization.
Area of Science:
- Cardiology
- Diagnostic Testing
- Interventional Cardiology
Background:
- Deciding on preoperative coronary angiography based on noninvasive cardiac testing is challenging.
- Expert agreement on specific noninvasive test criteria for angiography is lacking.
Purpose of the Study:
- To identify noninvasive cardiac test results with expert consensus for indicating preoperative coronary angiography.
- To establish criteria for performing coronary angiography based on noninvasive testing.
Main Methods:
- Thirty experts (24 diagnostic, 6 clinical cardiology) reviewed hypothetical noninvasive test results.
- Experts provided commentary on statements regarding indications for coronary angiography.
Main Results:
- Agreement reached on performing catheterization for specific findings: exercise electrocardiographic ischemia with >10 mm Hg blood pressure drop.
- Agreement on stress perfusion scan reversibility in ≥50% of single-photon emission computed tomographic slices.
- Agreement on stress echocardiography ischemia in >5 segments, ≥2 coronary artery zones, or 4 left anterior descending coronary artery segments.
Conclusions:
- Coronary angiography is indicated for noninvasive test results showing large zones of myocardial ischemia.
- Limited ischemia or isolated test abnormalities without significant findings do not necessitate coronary angiography.
Abstract:
Whether to perform coronary angiography on the basis of preoperative noninvasive cardiac testing remains a difficult decision. We hypothesized that there are noninvasive test results for which experts have general agreement about the indication for preoperative coronary angiography. We asked 30 experts (24 in specific diagnostic tests and six in clinical cardiology) to comment on statements regarding hypothetical noninvasive test results. There was agreement that catheterization should be performed for (1) exercise electrocardiographic ischemia with a blood pressure drop > 10 mm Hg, (2) stress perfusion scan reversibility in one half or more of single-photon emission computed tomographic slices, and (3) stress echo ischemia in more than five segments, two or more coronary artery zones, or four left anterior descending coronary artery segments. Therefore coronary angiography should be performed for results of noninvasive tests that indicate large zones of myocardial ischemia and not for limited ischemia or test abnormalities without other significant findings.