The utility of a ‘non-significant’ coronary angiogram

Abstract

Summary Background Coronary angiography is the gold standard for assessing coronary artery disease (CAD). In many patients with chest pain, no or mild CAD (< 50% stenosis) is found. It is uncertain whether this ‘non‐significant’ result influences management and outcomes. We reviewed characteristics and outcomes in a contemporary cohort of chest pain referrals who had mild or absent CAD on coronary angiography. Method All patients undergoing coronary angiography at Auckland City Hospital during July 2010–October 2011 were reviewed (n = 2983). Of these, 12.3% (n = 366) underwent coronary angiography for evaluation of chest pain and were found to have absent or mild CAD. These patients were followed up for 2.3 ± 0.6 years. Results Mean age was 60.0 ± 12.3 years, 56.1% were female. The ECG was abnormal in 55.0% of patients. Stress testing for inducible ischaemia was undertaken in 40.7% of patients and was abnormal in 57.7%. Following angiography, 43.2% had no changes to cardiac medications. Additional drug therapy (aspirin, statin, beta‐blockers, ACE‐inhibitor) was commenced in around 14.2–22.1% of cases. These drugs were discontinued in 4.1–8.2% of patients. Rates of major adverse cardiovascular events and readmissions with chest pain were 0.3% (1) and 1.9% (7) respectively at 30 days, and 1.9% (7) and 6.0% (22) at 1 year. Conclusion Although even non‐obstructive atheroma may justify medical therapy to limit disease progression, our findings may suggest that in these cases, invasive coronary angiography, may not lead to the patient/physician reassurance justified by historical data.

Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low‐risk chest pain in the emergency department

“…The incidence of all‐cause mortality and MI was 1.32/100 person‐years, (95% CI 1.02–1.62), meaning 1.32 cases are expected for 100 patients followed for 1 year, or 0.66 cases for 100 patients followed for 2 years 69–73 …”

“…The other observational studies did not separately analyze those without any stenosis versus those with <50% stenosis 69–73 …”

“…The incidence of all-cause mortality and MI was 1.32/100 personyears, (95% CI 1.02-1.62), meaning 1.32 cases are expected for 100 patients followed for 1 year, or 0.66 cases for 100 patients followed for 2 years. [69][70][71][72][73] The other observational studies did not separately analyze those without any stenosis versus those with <50% stenosis. [69][70][71][72][73] The data available suggest that the likelihood of non-fatal MI or all-cause mortality within 5 years is very low in this group of patients with coronary stenosis between 1% and 49% (Appendix 4).…”

“…[69][70][71][72][73] The other observational studies did not separately analyze those without any stenosis versus those with <50% stenosis. [69][70][71][72][73] The data available suggest that the likelihood of non-fatal MI or all-cause mortality within 5 years is very low in this group of patients with coronary stenosis between 1% and 49% (Appendix 4).…”