Pre-Coronary Angiography Testing

Initial Clinical Assessment and Basic Testing

The European Society of Cardiology recommends clinical risk stratification using age, ECG findings, anginal threshold, presence of diabetes, chronic kidney disease (CKD), and left ventricular ejection fraction (LVEF) before any invasive procedure 1, 2, 4
A 12-lead ECG must be obtained to assess for ST-segment changes, prior infarction, conduction abnormalities, and left ventricular hypertrophy 4, 5
Laboratory testing should include troponin T or I, CK-MB, renal function (creatinine/eGFR), and high-sensitivity C-reactive protein and/or fibrinogen should be considered (Class IIa) 1, 4, 5

For low to moderate risk (>5%–50% Pre-Test Probability), coronary CT angiography (CCTA) is the preferred initial test (Class I recommendation) 1, 2, 3, 4, 7
For moderate to high risk (>15%–85% Pre-Test Probability), functional imaging is recommended as the initial test (Class I) 1, 2, 3, 4, 7
Stress echocardiography, SPECT or PET myocardial perfusion imaging, and stress CMR perfusion imaging can be used to diagnose and quantify ischemia 1, 2, 3, 4, 7

The American College of Cardiology recommends proceeding directly to invasive coronary angiography without non-invasive testing if severe symptoms are refractory to medical therapy, angina occurs at low exercise levels, or there is hemodynamic instability (Class I) 1, 2, 3
Survived sudden cardiac death or life-threatening ventricular arrhythmia, symptoms and signs of heart failure, unstable angina, and de novo symptoms highly suggestive of obstructive CAD occurring at low exercise levels are indications for direct angiography 6, 8, 9

Radial artery access is the preferred access site (Class I recommendation) when invasive coronary angiography (ICA) is indicated 1, 3, 7
Coronary pressure assessment must be available during ICA to evaluate functional severity of intermediate non-left main stenoses prior to revascularization (Class I) 1, 3, 7

Do not perform angiography in patients who elect not to undergo revascularization or are not candidates due to comorbidities (Class III) 6
Do not rely solely on anatomic stenosis severity—functional assessment with FFR/iFR is essential for intermediate lesions 1, 2, 3

The American College of Cardiology notes that 4% of coronary angiograms were of unacceptable quality and 48% had technical deficiencies in a New York State sample, with only 70% interobserver agreement 6