Selective coronary angiography: Should be first choice for angina patients? - Hoàng Văn Sỹ

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 ?

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Hoàng Văn Sỹ MD, PhD 
University of Medicine & Pharmacy, Ho Chi Minh City 
Selective coronary angiography: 
should be first choice for 
angina patients? 
All roads lead to Rome ! 
Appropriateness of diagnostic catheterization for 
suspected coronary artery disease in New York State 
80 
70 
60 
50 
40 
30 
20 
10 
0 
O
p
e
ra
to
r 
R
at
e
, %
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 
Hannan E L et al. Circ Cardiovasc Interv. 2014;7:19-27 
24,9% 
64% 
90% 
N=8986 N=2240 N=1434 
2012 AUC for diagnostic catheterization 
no prior noninvasive stress testing 
Patel MR et al. J Am Coll Cardiol. 2012;59(22):1-33 
Risk Assessment 
Low Intermediate High 
Asymtomatic Global 
CAD Risk I I U 
Symptomatic 
Pretest Probability I U A 
Anatomy-based risk stratification is the clinical 
gold standard in high-probability patients ! 
Appropriate Use Criteria = AUC 
Determination of Appropriateness Score 
Parikh MA. TCT 2014 
Appropriateness 
Designation score 
AHA/ACC 
Rec 
Levele of 
Evid. 
Additional Published 
Characteristics of Appropriate 
Imaging Tests 
Appropriate 
9 I 
IIa 
IIb 
A – B 
C 
Wide spectrum of patients 
studied 
No patient selection bias 
(consecutive) 
All patient image results verified 
(“gold standard” or prognosis) 
Blinded interpretation 
Reproducible accquisition and 
interpretation 
8 
7 
Uncertain 
6 
IIb 
B – C 
5 
4 
Inappropriate 
3 
III 
C 
A - B 2 
1 
Risk vs Benefit 
St. Michel’s. inspired Care, Inspiring Science 
ACCF/ASNC 
Appropriate 
Use of MPS 
Criteria 
RISK 
BENEFIT 
Exposure Risk Is 
Not Warranted 
Given No Clear 
Benefit 
No Clear Benefit 
To Guide 
Therapeutic 
Decision Making 
RISK 
BENEFIT 
Added Benefit To 
Guide Therapeutic 
Decision Making 
Exposure Risk Is Farless 
Than Potential CV 
Risk Reduction 
Following Targeted 
Treatment 
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 
Ko et al. ACC 2012 
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) 
Adj HR 0.57 
(0.28-1.16) 
Adj HR 0.61 
(0.42-0.88) 
19% of cohort 20% of cohort 61% of cohort 
% 
Approach to diagnosis of suspected IHD 
11 Fihn SD et al. JACC 2012;24:2564–603 
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 
Consider coronary revascu. 
to improve symptoms 
Successful treatment ? 
Initiate guideline directed medical 
therapy; 
Consider coronary revascularization 
to improve survival 
Test results suggest high risk 
coronary lesions ? 
Exercise or cardiac imaging study 
Comprehensive clinical assessment of risk, including 
personal characteristics, coexisting cardiac and 
medical condition and health status 
Intermediate or high risk UA ? 
Suspected Ischemic Heart Disease 
(or change in clinical status in a patient with known IHD) 
yes 
no 
yes 
no 
no 
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. 
12 Fihn SD et al. JACC 2012;24:2564–603 
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 
13 European Heart Journal (2013) 34, 2949–3003 
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. 
15 European Heart Journal (2013) 34, 2949–3003 
Patients with SIHD who have survived sudden cardiac 
death or potentially life-threatening ventricular 
arrhythmia should undergo coronary angiography to 
assess cardiac risk. 
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. 
I IIa IIb III 
Coronary Angiography as an Initial 
Testing Strategy to Assess Risk 
I IIa IIb III 
Fihn SD et al. JACC 2012;24:2564–603 
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. 
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. 
I IIa IIb III 
Coronary Angiography to Assess Risk After Initial 
Workup With Noninvasive Testing 
I IIa IIb III 
Fihn SD et al. JACC 2012;24:2564–603 
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. 
I IIa IIb III 
Coronary Angiography to Assess Risk After Initial 
Workup With Noninvasive Testing (cont.) 
I IIa IIb III 
Fihn SD et al. JACC 2012;24:2564–603 
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. 
I IIa IIb III 
No Benefit 
Coronary Angiography to Assess Risk After Initial 
Workup With Noninvasive Testing (cont.) 
I IIa IIb III 
No Benefit 
Fihn SD et al. JACC 2012;24:2564–603 
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. 
I IIa IIb III 
No Benefit 
Coronary Angiography to Assess Risk After Initial 
Workup With Noninvasive Testing (cont.) 
I IIa IIb III 
No Benefit 
Fihn SD et al. JACC 2012;24:2564–603 
SPARC Registry: Therapeutic 
changes after non-invasive testing 
Hachamovitch et al. JACC 2012;59:462-474 
1% 
1,703 int/high risk pts with CCTA, SPECT or PET 
Among pts referred for cath, 63% had obstractive CAD 
Adverse outcomes related to 
underutilization of coronary angiography 
Hemingway et al. Annals if Int Med 2008 
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) 
Cornerstone of management of stable CAD 
23 European Heart Journal (2013) 34, 2949–3003 
1. First make the diagnosis: is this really CAD ??? 
2. Risk-stratify the patient and institute therapeutic 
maesures that: 
 Improve prognosis 
 Improve symtoms 
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 
Approach to diagnosis of suspected IHD 
24 European Heart Journal (2013) 34, 2949–3003 
Recent implementation of the AUC 
Newsweek 8/1/11 

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