Coronary Angiography: What is it?

Why undergo coronary angiography?

Coronary angiography is an invasive radiological diagnostic method that allows visualization of the coronary arteries using radiopaque contrast agents. It is indicated for the diagnosis and treatment of coronary artery disease and should be performed if the potential procedural risks are outweighed by the benefits of diagnosing significant coronary artery disease and considering a therapeutic procedure. It should also be performed to rule out coronary artery disease in cases of valvular surgery, before high-risk non-cardiac surgery, or in individuals with equivocal provocation tests. Other coronary diseases that can be diagnosed by coronary angiography include congenital anomalies of the origin and course of the coronary arteries, coronary fistulas, coronary spasms, the presence of a coronary embolism, coronary arteritis, and myocardial bridges. In addition, coronary angiography allows both the definition of the anatomical pathway and the identification of the type of coronary dominance.

As this is an invasive examination, coronary angiography is not systematically performed on all patients, but the physician must first assess the patient's medical history, clinical examination, risk factors for coronary artery disease, comorbidities (other diseases), and weigh the risk of complications against the potential benefits. A coronary angiography can be scheduled or performed as an emergency.

The most important indications for coronary angiography are:

• Stable angina: As this is an invasive examination, coronary angiography is only scheduled after other first-level examinations (electrocardiogram, echocardiography, stress test) and, less frequently, second-level examinations (angio-CT, myocardial perfusion scintigraphy);
• Unstable angina: After basic examinations (ECG, echocardiography, troponin), a short-term stress test is scheduled and, if positive, a coronary angiography is planned. In hemodynamically unstable patients with malignant arrhythmias and symptoms that do not regress with appropriate treatment, coronary angiography should be performed as an emergency;
• Acute myocardial infarction: In this case, coronary angiography is mandatory and generally most useful when performed within the first two hours of symptom onset;
• Dilated cardiomyopathy;

Before cardiac surgery (e.g., valve replacement):

• in women over 55 years of age;
• in men over 45 years of age;
• in all individuals, regardless of age, who present numerous cardiac risk factors suggesting the presence of coronary stenosis;
• Cardiac arrest (requiring cardiopulmonary resuscitation), in a patient with unknown heart disease;

How is a coronary angiography performed?

Coronary angiography is an invasive examination, which involves the administration of a contrast agent via an intravascular catheter. Usually, the catheter insertion, performed during the examination in a sterile environment, takes place at the level of the radial artery of the arm, or the femoral artery. Once access to the artery has been gained, the catheter is placed in the aortic valve, where the accesses to the right and left coronary arteries are located: this provides an image as descriptive as possible of the patient's cardiovascular situation.

Coronary angiography, which is part of diagnostic cardiac catheterization, can also be performed in conjunction with biological and radiological examinations of other vessels or cardiac chambers to obtain a complete diagnostic assessment of the patient's cardiovascular status and any cardiac disorders. Although it is an invasive diagnostic procedure, this examination is not painful for the patient: indeed, coronary angiography is performed under local anesthesia. The examination lasts 30-40 minutes to one hour, but it is generally performed after a day of hospitalization.

Coronary angiography is not without risk for the patient undergoing it, so the physician generally only prescribes this diagnostic examination if the benefits of early detection of coronary artery disease outweigh the risks of the examination. Major complications, which occur at a frequency of 0.23%, include the risk of cardiovascular events and strokes. On the other hand, minor complications, which occur at a frequency of 1%, include local complications at the vessel access site, arrhythmias, allergic reactions, renal toxicity due to the contrast agent, dissection of the coronary arteries, and heparin-induced hemorrhages.

Therefore, coronary angiography, in addition to being the diagnostic standard for identifying coronary artery disease, is often an integral part of coronary angioplasty surgery. Thanks to coronary angiography, it is possible to visualize the coronary arteries in real time and define the following information in particular.

• the position, length, diameter, and contour of the coronary arteries;
• the possible presence and severity of obstructions of the lumen of the coronary arteries and narrowing of the heart arteries;
• the characteristics of the obstruction, i.e., the presence of atherosclerotic plaque, thrombus, dissections, coronary spasms, or myocardial bridges;
• the characteristics of blood flow;
• the possible presence and extent of collateral circulation, formed following an occlusion or cardiovascular event;
• the presence of congenital diseases affecting the course of the coronary arteries;

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How to prepare for a coronary angiography?

Preparation for a coronary angiography can be summarized as follows:

• Patient consent, who must be informed of the potential risks associated with the procedure;
• Blood sample collection, to assess the patient's general health status;
• Collection of information on the patient's usual medications (paying particular attention to insulin and oral anticoagulants), which must be discontinued before the procedure;
• Assessment of the need for anti-allergic preparation based on cortisone (in case of known or even possible allergy to the contrast agent), or preparation for renal failure (to avoid nephropathy due to the contrast agent);
• Hair removal after disinfection, of the area through which the catheter will be introduced;
• Fasting for at least 8 hours;

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