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Under which conditions is angiography needed in patients who have 'stable angina')? In other words, what are the 'indications' of angiography in such patients? The angiography is done with a view to perform revascularization with angioplasty or coronary artery bypass surgery (CABG).

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Guidelines from different medical societies are available on this subject:

2011 NICE guidelines: https://www.nice.org.uk/guidance/cg126
2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline : http://content.onlinejacc.org/article.aspx?articleid=1391404
2013 ESC guidelines: http://eurheartj.oxfordjournals.org/content/ehj/early/2013/08/28/eurheartj.eht296.full.pdf
2014 ESC/EACTS Guidelines: http://eurheartj.oxfordjournals.org/content/early/2014/08/28/eurheartj.ehu278
2014 Canadian Cardiovascular Society Guidelines: http://www.onlinecjc.ca/article/S0828-282X%2814%2900356-0/abstract

Briefly, medication are the first line treatment for stable angina.

Angiography and revascularization (angioplasty or coronary bypass surgery) are needed only for patients whose angina is resulting in a moderate to severe limitation of daily activities despite adequate medication.

For patients with mild symptoms, a stress test (such as stress MIBI scan) should be performed and angiography + revascularization may be helpful if > 10% of myocardium (heart muscle) is showing signs of ischemia.

Persons whose angina is controlled on medication as well as persons who have a negative stress test are not at high risk of heart attacks and death and hence do not need angiography and revascularization.

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Please see the ACC/AHA guidelines (non-updated 1999, most recent "update" 2014) on this matter. You are asking a very good question. This is an excerpt from the 2014 update:

GDMT = guideline directed medical [drug] therapy

SIDH = Stable ischemic heart disease

Coronary revascularization = cardiac catheterization + procedure to open up arteries

Invasive Testing for Diagnosis of Coronary Artery Disease in Patients With Suspected SIHD: Recommendations (New Section) See Online Data Supplement 1 for additional information.

Class I

  1. Coronary angiography is useful in patients with presumed SIHD who have unacceptable ischemic symptoms despite GDMT and who are amenable to, and candidates for, coronary revascularization. (Level of Evidence: C)

Class IIa

  1. Coronary angiography is reasonable to define the extent and severity of coronary artery disease (CAD) in patients with suspected SIHD whose clinical characteristics and results of noninvasive testing (exclusive of stress testing) indicate a high likelihood of severe IHD and who are amenable to, and candidates for, coronary revascularization.7–12 (Level of Evidence: C)
  2. Coronary angiography is reasonable in patients with suspected symptomatic SIHD who cannot undergo diagnostic stress testing, or have indeterminate or nondiagnostic stress tests, when there is a high likelihood that the findings will result in important changes to therapy. (Level of Evidence: C)

Class IIb

  1. Coronary angiography might be considered in patients with stress test results of acceptable quality that do not suggest the presence of CAD when clinical suspicion of CAD remains high and there is a high likelihood that the findings will result in important changes to therapy. (Level of Evidence: C)

Essentially, the goal is to find patients that are more likely to benefit from the intervention (cardiac catheterization). The above are simply indications for angiography in the said setting (stable angina). Other indications that are not covered therefore would include ST-elevation ACS, as well as non-ST elevation ACS, sudden cardiac death, heart failure +/- reduced ejection fraction, and pre-surgery routine cardiac catheterization (only for specific surgeries...).

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    Good answer but you are giving reference of 1999, which seems quite old. – rnso Mar 14 '16 at 17:28
  • Good point. The 1999 guidelines never had an update actually which is why it ended up being so old. The ACC/AHA addressed "updates" in different papers so it hard to collect them into just one document but I will change it to reference the most recent paper which is from 2014. Thank you!! – user3176 Mar 14 '16 at 20:43
  • Just edited it with an update. Thanks again – user3176 Mar 14 '16 at 20:56

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