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).
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.
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.
- 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)
- 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)
- 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)
- 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...).