CardioExchange Archive

CardioExchange, an NEJM practice community for medical professionals dedicated to improving cardiac patient care, was active from 2009 to 2015. CardioExchange fostered discussion between clinicians from across the globe.

March 11th, 2010

Low Diagnostic Yield of Elective Coronary Angiography

According to a recent study, of almost 400,000 patients referred for elective coronary angiography, only 38% had obstructive CAD.  Those with a positive noninvasive test before angiography were only moderately more likely to have obstructive CAD than those who did not undergo any testing (41% vs 35%, respectively).  However, in a comment in Journal Watch, Harlan Krumholz notes that the study’s reporting of noninvasive testing is inadequate for assessing the implications of positive results. Furthermore, the presence of typical symptoms was a much better predictor of CAD than a positive noninvasive test (ORs, 1.91 and 1.28, respectively); still, 30% of those referred for angiography had no anginal symptoms.

More than 9 million myocardial perfusion imaging studies are performed annually in the U.S.  How do we improve the quality of noninvasive testing?  In the absence of planned transplantation or valvular surgery, should asymptomatic patients be referred for coronary angiography?

Categories: General


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One Response to “Low Diagnostic Yield of Elective Coronary Angiography”

  1. William L Blanchet, MD says:
    March 19, 2010 at 1:20 am

    What do we want to accomplish?

    We remain fascinated with finding and treating obstruction despite the fact that we know most heart attacks occur in non-obstructed vessels (until the plaque fractures and the vessel fills with clot). In addition, we have demonstrated in several studies, no net improvement in outcomes with revascularization. I therefore question the relevance of this negative study.

    I would propose that the presence of any CAD, obstructive or not should be considered a positive finding. Even though the lumen might be open, perhaps it had a clot in it yesterday which has auto-lysed by the time the cath was performed or perhaps the obstruction at a micro-vascular level has led to symptoms.

    That said, we have non-invasive ways of looking for CAD other than Cath and I think those studies such as CAC and carotid US need to be utilized more often and patients treated medically. It is time to rethink the diagnostic cath.

    Competing Interests: I have an ownership interest in a facility that can do EBT calcium imaging and ultrasound. I practice Internal Medicine and despise heart attacks.