ACC/AHA Guidelines for Coronary Angiography: Executive Summary and Recommendations
1999; Lippincott Williams & Wilkins; Volume: 99; Issue: 17 Linguagem: Inglês
10.1161/01.cir.99.17.2345
ISSN1524-4539
AutoresPatrick J. Scanlon, David P. Faxon, Anne‐Marie Audet, Blasé A. Carabello, Gregory Dehmer, Kim A. Eagle, Ronald D. Legako, Donald F. Leon, John Murray, Steven E. Nissen, Carl J. Pepine, Rita Watson, James L. Ritchie, Raymond J. Gibbons, Melvin D. Cheitlin, Kim A. Eagle, Timothy J. Gardner, Arthur Garson, Richard O. Russell, Thomas J. Ryan, Sidney C. Smith,
Tópico(s)Acute Myocardial Infarction Research
ResumoHomeCirculationVol. 99, No. 17ACC/AHA Guidelines for Coronary Angiography: Executive Summary and Recommendations Free AccessOtherPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessOtherPDF/EPUBACC/AHA Guidelines for Coronary Angiography: Executive Summary and Recommendations A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Coronary Angiography) Developed in collaboration with the Society for Cardiac Angiography and Interventions Patrick J. Scanlon, David P. Faxon, Anne-Marie Audet, Blase Carabello, Gregory J. Dehmer, Kim A. Eagle, Ronald D. Legako, Donald F. Leon, John A. Murray, Steven E. Nissen, Carl J. Pepine and Rita M. Watson James L. Ritchie, Raymond J. Gibbons, Melvin D. Cheitlin, Kim A. Eagle, Timothy J. Gardner, Arthur GarsonJr, Richard O. RussellJr, Thomas J. Ryan and Sidney C. SmithJr Patrick J. ScanlonPatrick J. Scanlon , David P. FaxonDavid P. Faxon , Anne-Marie AudetAnne-Marie Audet , Blase CarabelloBlase Carabello , Gregory J. DehmerGregory J. Dehmer , Kim A. EagleKim A. Eagle , Ronald D. LegakoRonald D. Legako , Donald F. LeonDonald F. Leon , John A. MurrayJohn A. Murray , Steven E. NissenSteven E. Nissen , Carl J. PepineCarl J. Pepine and Rita M. WatsonRita M. Watson James L. RitchieJames L. Ritchie , Raymond J. GibbonsRaymond J. Gibbons , Melvin D. CheitlinMelvin D. Cheitlin , Kim A. EagleKim A. Eagle , Timothy J. GardnerTimothy J. Gardner , Arthur GarsonJrArthur GarsonJr , Richard O. RussellJrRichard O. RussellJr , Thomas J. RyanThomas J. Ryan and Sidney C. SmithJrSidney C. SmithJr and Committee Membersand Task Force Members Originally published4 May 1999https://doi.org/10.1161/01.CIR.99.17.2345Circulation. 1999;99:2345–2357This document revises and updates the original "Guidelines for Coronary Angiography," published in 1987. This executive summary and recommendations appears in the May 4, 1999, issue of Circulation. The guidelines in their entirety, including the American College of Cardiology/American Heart Association (ACC/AHA) class I, II, and III recommendations, are published in the May 1999 issue of the Journal of the American College of Cardiology. Reprints of both the full text and executive summary and recommendations are available from both organizations.The frequent and still growing use of coronary angiography, its relatively high costs, its inherent risks, and the ongoing evolution of its indications provide the reasons for this revision. The committee appointed to develop this document included private practitioners and academicians who were selected to represent both experts in coronary angiography and senior clinician consultants. Representatives from the family practice and internal medicine professions were also included on the committee. In addition to reviewing the original document, the committee conducted a search of the literature for the 10 years preceding development of these guidelines. Evidence was compiled and ranked by the committee. Whereas randomized trials are often available for reference in the development of treatment guidelines, randomized trials regarding the use of diagnostic procedures such as coronary angiography are rarely available.This document uses the ACC/AHA classifications of class I, II, and III. These classes summarize the indications for coronary angiography as follows:Class I: Conditions for which there is evidence and/or general agreement that this procedure is useful and effective.Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of performing the procedure.Class IIa: Weight of evidence/opinion is in favor of usefulness/ efficacy.Class IIb: Usefulness/efficacy is less well established by evidence/opinion.Class III: Conditions for which there is evidence and/or general agreement that the procedure is not useful/effective and in some cases may be harmful.The weight of evidence in support of the recommendation for each listed indication is presented as follows:Level of Evidence A: The presence of multiple randomized clinical trials.Level of Evidence B: The presence of a single randomized trial or nonrandomized studies.Level of Evidence C: Expert consensus.The full report discusses some general considerations concerning the definition and purpose of coronary angiography, its accuracy and reproducibility, including a discussion of digital storage of coronary angiography, its limitations, risks and relative contraindications, the selection of a contrast agent for coronary angiography, pharmacological assessment for coronary spasm at the time of coronary angiography, and the use, cost, and cost-effectiveness of coronary angiography. This executive summary does not detail these general considerations, and the reader is referred to the full document for discussion of these important topics.The full document also discusses applications of coronary angiography in specific disease states and makes recommendations for its appropriate use in these conditions. This executive summary includes highlights of these discussions and a complete list of recommendations.The full document contains appendices that present definitions of angiographic coronary anatomy, special considerations, alternative imaging modalities, the Canadian Cardiovascular Society (CCS) classification of angina and the desired elements of a coronary angiographic report. This executive summary does not include any of the discussions in these appendices, but recommendations for the use of alternative imaging modalities are included at the end of this summary.This report is not intended to provide strict indications or contraindications for coronary angiography because, in the individual patient, multiple other considerations may be relevant, including the family setting, occupational needs, and individual lifestyle preferences. Rather, the report is intended to provide general guidelines that may be helpful to the practitioner and various healthcare agencies.I. General Considerations Regarding Coronary AngiographyCoronary angiography is defined as the radiographic visualization of the coronary vessels after injection of radiopaque contrast media. It is most commonly performed with specialized intravascular catheters. The procedure is usually included as part of cardiac catheterization, which may also involve angiography of other vascular structures, such as the aorta and left ventricle.The purpose of coronary angiography is to define the coronary anatomy and the degree of luminal obstruction of the coronary arteries. It is most commonly used to determine the presence and extent of obstructive coronary artery disease (CAD) and to assess the feasibility and appropriateness of various forms of therapy, such as revascularization by percutaneous or surgical interventions. It is also used when the diagnosis of coronary disease is uncertain and coronary disease cannot be reasonably excluded by noninvasive techniques.The risk of major complications is 1 000 000 patients in 1993, making it the second most frequent in-hospital operative procedure performed in the United States. Approximately 48% of all catheterizations are performed in patients ≥65 years. The use of catheterization continues to grow. Given the predicted growth in population and aging of the population, it is possible that by 2010 3 000 000 procedures will be performed annually in the United States. The striking variations in use of coronary angiography in the United States have led to concerns about its appropriateness. A number of studies have evaluated this issue, and the results suggest that the incidence of inappropriate use of coronary angiography is relatively low, ranging from 4% to 18%.II. Coronary Angiography for Specific ConditionsA. Known or Suspected CAD1. Stable AnginaPatients with CAD may become symptomatic in many ways, but most commonly develop angina pectoris. Not all stable chest pain syndromes are truly anginal. It has been suggested that it is useful to characterize chest pain as typical angina, probable angina, and nonspecific chest pain because these groupings are predictive of the presence of CAD.Asymptomatic patients with known or suspected CAD have had no symptoms to suggest cardiac ischemia in the previous 6 weeks. A subgroup of these patients have silent ischemia when tested noninvasively. In general, the results of these tests are related to the functional severity of CAD and are predictors of outcome, independent of the perception of or severity of symptoms. The term known coronary artery disease means that CAD has been documented by either angiography or prior confirmed myocardial infarction (MI). Asymptomatic patients with known CAD form 1 group of patients who were never symptomatic but in whom CAD was documented for other reasons. A second group includes those who were previously symptomatic but who are currently asymptomatic. The term suspected coronary artery disease refers to the presence of clinical characteristics that suggest high risk for CAD and its related adverse outcomes in asymptomatic patients.Treatment of symptomatic patients should include assessment of severity of angina. The CCS classification of angina provides a useful guide for assessment of typical or probable angina. Severely symptomatic patients (CCS class III or IV) should undergo coronary angiography after medical therapy. Coronary angiography should also be considered for patients treated medically who demonstrate serial deterioration on noninvasive testing but who do not have high-risk features as well as patients whose angina accelerates or intensifies despite adequate medical therapy. Rarely, patients with minimal symptoms whose occupation poses a risk to themselves or others should also undergo coronary angiography, even in the absence of high-risk markers for adverse outcome. Those patients with stable angina who respond to therapy and are currently asymptomatic should undergo noninvasive testing for risk stratification. Table 1 summarizes noninvasive test results that predict high risk for adverse outcome. High-risk patients are defined as those who are expected to have reduced event-free survival, such as patients with underlying left main coronary artery stenosis or severe multivessel disease. In general, the lower the resting left ventricular ejection fraction (LVEF), the higher the risk for adverse outcome. Figure 1 explains the Duke Treadmill Score and its relationship to prognosis. Even when multiple clinical findings suggest the likelihood of significant underlying coronary disease, it is important to have objective markers from noninvasive tests to help predict outcome. A scheme for noninvasive evaluation of a patient with suspected coronary disease is shown in Figure 2. Noninvasive procedures for identifying patients with stress-induced ischemia, especially those at high risk for adverse outcome, should remain the primary means of risk stratification. There is general agreement that coronary angiography is indicated for patients found to have high-risk abnormalities on noninvasive testing. There is varying opinion as to when coronary angiography should be performed in asymptomatic patients for whom noninvasive testing indicates ischemia (ie, a high probability of CAD), but test criteria do not indicate a high risk for adverse outcome. In this subgroup, the presence of multiple clinical risk factors such as increased age or diabetes, occupation, or lifestyle become increasingly important considerations in determining whether coronary angiography should be performed. However, it should be recognized that no controlled studies show an advantage for angiography or revascularization for any of these clinical subsets.Although it has become common practice to perform periodic coronary angiography after heart transplantation, the prognostic benefit of this practice has not been clearly established.Adult patients successfully resuscitated from cardiac arrest who do not have clinical findings that suggest other causes generally have extensive CAD. In the absence of recognized precipitating factors such as acute MI, these patients are at high risk for recurrent cardiac arrest, and coronary angiography is of value in determining the underlying cause and planning the most appropriate therapeutic approach.Recommendations for Coronary Angiography in Patients With Known or Suspected CAD Who Are Currently Asymptomatic or Have Stable AnginaClass I1. CCS class III and IV angina on medical treatment. (Level of Evidence: B)2. High-risk criteria on noninvasive testing regardless of anginal severity (Table 1). (Level of Evidence: A)3. Patients who have been successfully resuscitated from sudden cardiac death or have sustained (>30 seconds) monomorphic ventricular tachycardia or nonsustained (<30 seconds) polymorphic ventricular tachycardia. (Level of Evidence: B)Class IIa1. CCS class III or IV angina, which improves to class I or II with medical therapy. (Level of Evidence: C)2. Serial noninvasive testing with identical testing protocols, at the same level of medical therapy, showing progressively worsening abnormalities. (Level of Evidence: C)3. Patients with angina and suspected coronary disease who, due to disability, illness, or physical challenge, cannot be adequately risk stratified by other means. (Level of Evidence: C)4. CCS class I or II angina with intolerance to adequate medical therapy or with failure to respond, or patients who have recurrence of symptoms during adequate medical therapy as defined above. (Level of Evidence: C)5. Individuals whose occupation involves the safety of others (eg, pilots, bus drivers, etc) who have abnormal but not high-risk stress test results or multiple clinical features that suggest high risk. (Level of Evidence: C)Class IIb1. CCS class I or II angina with demonstrable ischemia but no high-risk criteria on noninvasive testing. (Level of Evidence: C)2. Asymptomatic man or postmenopausal woman without known coronary heart disease with ≥2 major clinical risk factors and abnormal but not high-risk criteria on noninvasive testing (performed for indications stated in the ACC/AHA noninvasive testing guidelines). (Level of Evidence: C)3. Asymptomatic patients with prior MI with normal resting left ventricular function and ischemia on noninvasive testing but without high-risk criteria. (Level of Evidence: C)4. Periodic evaluation after cardiac transplantation. (Level of Evidence: C)5. Candidate for liver, lung, or renal transplant ≥40 years old as part of evaluation for transplantation. (Level of Evidence: C)Class III1. Angina in patients who prefer to avoid revascularization even though it might be appropriate. (Level of Evidence: C)2. Angina in patients who are not candidates for coronary revascularization or in whom revascularization is not likely to improve quality or duration of life. (Level of Evidence: C)3. As a screening test for CAD in asymptomatic patients. (Level of Evidence: C)4. After coronary artery bypass grafting (CABG) or angioplasty when there is no evidence of ischemia on noninvasive testing, unless there is informed consent for research purposes. (Level of Evidence: C)5. Coronary calcification on fluoroscopy, electron beam computed tomography, or other screening tests without criteria listed above. (Level of Evidence: C)2. Treatment of Patients With Nonspecific Chest PainChest pain syndromes that are not characteristic of angina have been previously called noncardiac, atypical, or angiographically negative chest pain, as well as chest pain of undetermined origin. Chest pain of this type is rarely due to myocardial ischemia, but when it is, less common causes of ischemia, such as variant angina, cocaine abuse, and syndrome X should be suspected. Other cardiac causes of nonspecific chest pain include mitral valve prolapse, myocarditis, pericarditis, and aortic dissection. Noncardiac causes include costochondritis and esophageal disorders. The latter has been implicated as a cause of nonspecific chest pain in 25% of patients. Noninvasive testing should be performed in patients with cardiovascular risk factors and those in whom a noncardiac cause has been excluded or unlikely.Recommendations for Coronary Angiography in Patients With Nonspecific Chest PainClass IHigh-risk findings on noninvasive testing. (Level of Evidence: B)Class IIaNone.Class IIbPatients with recurrent hospitalizations for chest pain who have abnormal (but not high-risk) or equivocal findings on noninvasive testing. (Level of Evidence:B)Class IIIAll other patients with nonspecific chest pain. (Level of Evidence: C)3. Unstable AnginaThe 1994 "Clinical Practice Guideline for Unstable Angina" (Agency for Health Care Policy and Research and the National Heart, Lung, and Blood Institute) is the basis for the recommendations in this section. Risk stratification of patients with unstable angina is outlined in Table 2. The guidelines recommend outpatient management for those judged to be at low risk at presentation. This group should undergo noninvasive testing; patients with high-risk criteria for adverse outcome as shown in Table 1 are then candidates for coronary angiography. Patients with unstable angina who are thought to be at intermediate or high risk for death or nonfatal MI at presentation should be admitted to the hospital for intensive medical treatment. Emergency or urgent cardiac catheterization should be performed and/or intra-aortic counterpulsation should be instituted in patients who do not respond after 1 hour of aggressive therapy or in those who have recurrence of symptoms after initial stabilization and are thus considered refractory. For patients whose condition stabilizes after initial treatment, either an "early invasive" or "early conservative" strategy may be undertaken. With the early invasive strategy, all hospitalized patients without contraindications receive elective cardiac catheterization within 48 hours. With the early conservative strategy, only patients with high-risk indications (prior revascularization, congestive heart failure (CHF), LVEF 1 year postoperatively. (Level of Evidence: C)3. Asymptomatic postbypass patient in whom a deterioration in serial noninvasive testing has been documented but who is not at high risk on noninvasive testing. (Level of Evidence: C)Class III1. Symptoms in a postbypass patient who is not a candidate for repeat revascularization. (Level of Evidence: C)2. Routine angiography in asymptomatic patients after percutaneous transluminal coronary angioplasty (PTCA) or other surgery, unless as part of an approved research protocol. (Level of Evidence: C)5. Acute MIAlthough coronary angiography may be performed during or after MI solely for diagnostic purposes, the vast majority of studies are done to evaluate the patient for a percutaneous or surgical revascularization procedure. Therefore, the appropriateness of performing coronary angiography after MI is, by necessity, linked to the efficacy of these revascularization procedures as measured by improved outcome for the patient. Guidelines covering PTCA, coronary artery bypass graft surgery, and management of acute MI have been published by the ACC/AHA Task Force on the Assessment of Diagnostic and Therapeutic Procedures within the past 5 years and include recommendations relevant to the use of coronary angiography.In practical terms, the use of coronary angiography in patients with acute MI is considered during 3 separate time periods. The first is related to the use of coronary angiography during recognition and treatment of MI in the emergency department. It is only applicable to patients who present with an acute evolving MI within a time frame when reperfusion therapy will likely be beneficial. It is useful to stratify these patients by the presence or absence of ST-segment elevation on the ECG. Because clinical outcomes, especially with thrombolysis, are similar, the committee included in the group with ST-segment elevation patients with typical ischemic chest pain and a new or presumed new left bundle-branch block (BBB) obscuring the ECG diagnosis of MI. In the presence of ongoing ischemic chest pain and ST-segment elevation (or left BBB), the clinician must quickly weigh the risks and benefits of reperfusion therapy and determine whether to use thrombolysis or mechanical techniques. Patients with ongoing ischemic chest pain but without ST-segment elevation are a distinct group with different indications for coronary angiography compared with those with ST-segment elevation.The second time period relates to the use of coronary angiography during the hospital-management phase, after completion of reperfusion therapy, if used, or immediately if reperfusion therapy is not used. Throughout the remainder of the hospital-management phase, the clinician is mainly concerned with treatment of various complications, such as arrhythmia, heart failure, or recurrent ischemia that may develop.The final time period is defined not by a specific time but rather by evaluations to determine the risk of future morbid events and the need for additional therapies. In these guidelines, the risk stratification phase refers to testing specifically performed in the patient with MI to determine if high-risk indicators are present.For a broad discussion of management and risk stratification (Figure 3) of patients with acute MI, the reader is referred to the full report of this committee and the 1996 "ACC/AHA Guidelines for the Management of Acute Myocardial Infarction."Recommendations for Coronary Angiography During the Initial Management of Acute MI (MI Suspected and ST Elevation or BBB Present)Coronary Angiography Coupled With the Intent to Perform Primary PTCAClass I1. As an alternative to thrombolytic therapy in patients who can undergo angioplasty of the infarct artery within 12 hours of the onset of symptoms or beyond 12 hours if ischemic symptoms persist, if performed in a timely fashion* by individuals skilled in the procedure† and supported by experienced personnel in an appropriate laboratory environment.‡ (Level of Evidence: A) *Performance standard: within 90 minutes. †Individuals who perform >75 PTCA procedures per year. ‡Centers that perform >200 PTCA procedures per year and have cardiac surgical capability.2. In patients who are within 36 hours of an acute ST elevation/Q-wave or new LBBB MI who develop cardiogenic shock, are <75 years of age, and in whom revascularization can be performed within 18 hours of the onset of shock.Class IIaAs a reperfusion strategy in patients who are candidates for reperfusion but who have a contraindication to fibrinolytic therapy, if angioplasty can be performed as outlined above in class I. (Level of Evidence: C)Class III1. In patients who are beyond 12 hours from onset of symptoms and who have no evidence of myocardial ischemia. (Level of Evidence: A)2. In patients who are eligible for thrombolytic therapy and are undergoing primary angioplasty by an unskilled operator in a laboratory that does not have surgical capability. (Level of Evidence: B)Recommendations for Early Coronary Angiography in the Patient With Suspected MI (ST-Segment Elevation or BBB Present) Who Has Not Undergone Primary PTCAClass INone.Class IIaCardiogenic shock or persistent hemodynamic instability. (Level of Evidence: B)Class IIb1. Evolving large or anterior infarction after thrombolytic treatment when it is believed that reperfusion has not occurred and rescue
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