Coronary Angiography for Debilitating Heart Failure with Low Ejection Fraction

Rationale for Coronary Angiography

• The American College of Cardiology recommends invasive coronary angiography as the gold standard for identifying revascularizable coronary disease in symptomatic heart failure patients with reduced ejection fraction, with a Class I recommendation (Level of Evidence B) for patients with HF who have angina or significant ischemia 1
• The European Society of Cardiology guidelines recommend invasive coronary angiography (Class I, Level C) in patients with HF and angina recalcitrant to pharmacological therapy or symptomatic ventricular arrhythmias 3
• The American College of Cardiology gives a Class IIa recommendation (Level C) for patients with chest pain that may or may not be cardiac in origin, or those with known/suspected CAD without angina to consider coronary angiography 1

When Non-Invasive Testing May Be Considered First

• The European Society of Cardiology guidelines suggest that non-invasive stress imaging may be considered (Class IIb, Level B) before the decision on revascularization to assess myocardial ischemia and viability 3

Critical Clinical Context

• The American College of Cardiology emphasizes that coronary angiography should be performed unless the patient is not eligible for revascularization of any kind, and that the decision hinges on whether the patient is a revascularization candidate, not on symptom severity alone 1
• Ensure the patient is medically stable enough for angiography and would be a candidate for revascularization based on age, comorbidities, and functional status 1
• If the patient has absolute contraindications to revascularization, then invasive angiography is not indicated regardless of symptom severity 1, 3