When is coronary angiography indicated in patients with stable angina on optimal medical therapy?

1 Answer

Indications for Coronary Angiography in Stable Angina: Class I (Strongly Recommended): 1. Persistent symptoms despite OMT (as in your patient) 2. High-risk stress test findings: >2mm ST depression, early positive (<5 METs), ST elevation on exercise, exercise-induced hypotension, large perfusion defect on nuclear imaging 3. Severe angina limiting daily activities 4. Suspected left main or proximal LAD disease 5. Reduced EF <50% with angina Class IIa (Reasonable): - Intermediate risk features on non-invasive testing - Inconclusive non-invasive testing When NOT to perform angiography: - Low-risk stress test, angina well-controlled on OMT - Patient not a revascularization candidate For your patient: Positive stress test + persistent symptoms on OMT = Class I indication for angiography. Proceed with coronary angiography. If significant stenosis found: - Single/two-vessel disease: PCI preferred - Three-vessel disease or left main: CABG generally preferred (especially in diabetics) - Use FFR/iFR to guide PCI decision in intermediate lesions (60-80% stenosis) Note: The ISCHEMIA trial showed that in stable angina, revascularization reduces angina symptoms but may not reduce MI/death compared to OMT alone in patients with preserved EF - discuss goals of treatment with patient.