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Selective coronary angiography:
should be first choice for
angina patients?
Hoàng Văn Sỹ MD, PhD
University of Medicine & Pharmacy, Ho Chi Minh City


All roads lead to Rome !


Appropriateness of diagnostic catheterization for
suspected coronary artery disease in New York State
80

Operator Rate, %

70
60
50
40
30
20

10
0

Appropriate

Uncertain

Inappropriate

Hannan E L et al. Circ Cardiovasc Interv. 2014;7:19-27


Appropriateness of diagnostic catheterization for
suspected coronary artery disease in New York State

90%

64%

24,9%

N=8986

N=2240

Hannan E L et al. Circ Cardiovasc Interv. 2014;7:19-27

N=1434


2012 AUC for diagnostic catheterization
no prior noninvasive stress testing
Risk Assessment
Low

Intermediate

High

Asymtomatic Global
CAD Risk

I

I

U

Symptomatic
Pretest Probability

I

U

A

Appropriate Use Criteria = AUC

Anatomy-based risk stratification is the clinical
gold standard in high-probability patients !
Patel MR et al. J Am Coll Cardiol. 2012;59(22):1-33


Determination of Appropriateness Score
Appropriateness
Designation score

Appropriate

AHA/ACC
Rec

Levele of
Evid.

Additional Published
Characteristics of Appropriate
Imaging Tests

9

I

8

IIa

7

IIb

No patient selection bias
(consecutive)

IIb

All patient image results verified

(“gold standard” or prognosis)

A–B
C

Wide spectrum of patients
studied

6
Uncertain

5
4

B–C

3
Inappropriate

2

1

Blinded interpretation
III

C
A-B

Reproducible accquisition and

interpretation

Parikh MA. TCT 2014


Risk vs Benefit
BENEFIT
RISK

No Clear Benefit
To Guide
Therapeutic
Decision Making

Exposure Risk Is
Not Warranted
Given No Clear
Benefit

ACCF/ASNC
Appropriate
Use of MPS
Criteria

RISK
Exposure Risk Is Farless
Than Potential CV
Risk Reduction
Following Targeted
Treatment

St. Michel’s. inspired Care, Inspiring Science

BENEFIT
Added Benefit To
Guide Therapeutic
Decision Making


Remember……
All medical therapy vs. revascularization
patients in highly cited RCTs were
triaged (pre-randomization) on the basis
of Angiography


But how many “inappropriate PCI’s”
were really getting done ?

Wall Street Journal, July 6, 2011
Data from P. Chan et al, JAMA 2011


Revascularization appropriateness in stable
CAD and 3-year death/recurrent ACS
1,625 pts from the VRPO Cohort Study
Pts with stable CAD and a significant stenosis (50% angio)

%
Adj HR 0.99

(0.48-2.02)

19% of cohort

Adj HR 0.57
(0.28-1.16)

Adj HR 0.61
(0.42-0.88)

20% of cohort

61% of cohort

Ko et al. ACC 2012


Approach to diagnosis of suspected IHD
Suspected Ischemic Heart Disease
(or change in clinical status in a patient with known IHD)
yes

Intermediate or high risk UA ?

Comprehensive clinical assessment of risk, including
personal characteristics, coexisting cardiac and
medical condition and health status
no

Exercise or cardiac imaging study

Test results suggest high risk
coronary lesions ?
Initiate guideline directed medical
therapy;
Consider coronary revascularization
to improve survival

yes
no

ACCF/AHA UA/NSTEMI
Guideline
Symptoms or finding
suggest high risk lesions
OR
Prior sudden death or
serious ventricular
arrhythmia
OR
Prior stent in unprotected
lef main coronary artery

Initiate guideline
directed medical therapy
no

Successful treatment ?

Consider coronary revascu.
to improve symptoms

Fihn SD et al. JACC 2012;24:2564–603

11


Invasive coronary angiography
• Plays a very limited role in the diagnosis of CAD.
• Diagnosis in patients with suspected SIHD who:
1. Have survived sudden death or serious ventricular
arrhythmias or
2. Have symptoms or findings that suggest high-risk
coronary lesions.

Fihn SD et al. JACC 2012;24:2564–603

12


Invasive coronary angiography
• Non-invasive testing can establish the likelihood of the presence of
obstructive coronary disease with an acceptable degree of certainty.
• ICA will only rarely be necessary in stable patients with suspected CAD,
for the sole purpose of establishing or excluding the diagnosis:
1.

Patients who cannot undergo stress imaging techniques,

2.

Patients with reduced LVEF < 50% and typical angina

3.

Patients with special professions, such as pilots (however, be indicated
following non-invasive risk stratification for determination of options for
revascularization.

4.

Patients have a high PTP and severe symptoms, or a clinical constellation
suggesting high event risk, early ICA without previous non-invasive risk
stratification maybe a good strategy to identify lesions potentially
amenable to revascularization

European Heart Journal (2013) 34, 2949–3003

13


Noninvasive Risk Stratification

*Although the published data are limited; patients with these findings will probably not be at low risk in the presence
of either a high-risk treadmill score or severe resting LV dysfunction (LVEF <35%).

Fihn SD et al. JACC 2012;24:2564–603


Invasive coronary angiography
• ICA should not be performed in patients with

angina
1. Refuse invasive procedures, prefer to avoid
revascularization,
2. Not candidates for PCI or CABG,
3. Or revascularization is not expected to improve
functional status or quality of life.

European Heart Journal (2013) 34, 2949–3003

15


Coronary Angiography as an Initial
Testing Strategy to Assess Risk
I IIa IIb III

Patients with SIHD who have survived sudden cardiac
death or potentially life-threatening ventricular
arrhythmia should undergo coronary angiography to
assess cardiac risk.

I IIa IIb III

Patients with SIHD who develop symptoms and signs of
heart failure should be evaluated to determine
whether coronary angiography should be performed
for risk assessment.

Fihn SD et al. JACC 2012;24:2564–603

Coronary Angiography to Assess Risk After Initial
Workup With Noninvasive Testing
I IIa IIb III

Coronary arteriography is recommended for patients with
SIHD whose clinical characteristics and results of
noninvasive testing indicate a high likelihood of severe IHD
and when the benefits are deemed to exceed risk.

I IIa IIb III

Coronary angiography is reasonable to further assess risk in
patients with SIHD who have depressed LV function (EF
<50%) and moderate risk criteria on noninvasive testing
with demonstrable ischemia.

Fihn SD et al. JACC 2012;24:2564–603


Coronary Angiography to Assess Risk After Initial
Workup With Noninvasive Testing (cont.)
I IIa IIb III

I IIa IIb III

Coronary angiography is reasonable to further assess risk in
patients with SIHD and inconclusive prognostic information
after noninvasive testing or in patients for whom
noninvasive testing is contraindicated or inadequate.

Coronary angiography for risk assessment is reasonable for
patients with SIHD who have unsatisfactory quality of life
due to angina, have preserved LV function (EF >50%), and
have intermediate risk criteria on noninvasive testing.

Fihn SD et al. JACC 2012;24:2564–603


Coronary Angiography to Assess Risk After Initial
Workup With Noninvasive Testing (cont.)
I IIa IIb III

No Benefit

I IIa IIb III

No Benefit

Coronary angiography for risk assessment is not
recommended in patients with SIHD who elect not to
undergo revascularization or who are not candidates
for revascularization because of comorbidities or
individual preferences .
Coronary angiography is not recommended to further
assess risk in patients with SIHD who have preserved
LV function (EF >50%) and low-risk criteria on
noninvasive testing.
Fihn SD et al. JACC 2012;24:2564–603

Coronary Angiography to Assess Risk After Initial
Workup With Noninvasive Testing (cont.)
I IIa IIb III

No Benefit
I IIa IIb III

No Benefit

Coronary angiography is not recommended to assess
risk in patients who are at low risk according to clinical
criteria and who have not undergone noninvasive risk
testing.
Coronary angiography is not recommended to assess
risk in asymptomatic patients with no evidence of
ischemia on noninvasive testing.

Fihn SD et al. JACC 2012;24:2564–603


SPARC Registry: Therapeutic
changes after non-invasive testing
1,703 int/high risk pts with CCTA, SPECT or PET
Among pts referred for cath, 63% had obstractive CAD

1%

Hachamovitch et al. JACC 2012;59:462-474

Adverse outcomes related to
underutilization of coronary angiography
9356 UK pts with recent onset chest pain in whom angina was suspected
2 panels rated appropriateness using RAND methodology
57% (Panel A), 71% (Panel B) underuse of angiography for appropriate pts
Adjusted HR of death/ACS if angiography was NOT performed

Panel A

Panel B

Inappropriate

0.69
(0.47-1.01)

0.52
(0.26-1.03)

Uncertain

1.98
(1.17-3.36)

1.16
(0.79-1.72)

Appropriate

2.67

(1.77-4.01)

2.47
(1.72-3.55)

Hemingway et al. Annals if Int Med 2008


Cornerstone of management of stable CAD
1. First make the diagnosis: is this really CAD ???
2. Risk-stratify the patient and institute therapeutic
maesures that:
 Improve prognosis
 Improve symtoms

European Heart Journal (2013) 34, 2949–3003

23


Approach to diagnosis of suspected IHD
Clinical assessment of the probability that SCAD is present in
a particular patient (determination of PTP)

Non-invasive testing to establish the diagnosis of SCAD
or non-obstructive atheroslerosis

Stratification for risk of subsequent events - usually on the
basis of available non-invasive tests - in order to select pts
who may benefit from invasive investigation

European Heart Journal (2013) 34, 2949–3003

24


Recent implementation of the AUC

Newsweek 8/1/11