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Yield of 5,536 Diagnostic Coronary Arteriographies: Results from a Data Registry Article in Cardiology · February 2002 DOI: 10.1159/000067318 · Source: PubMed
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Cardiac Catheterization and Interventional Cardiology Cardiology 2002;98:191–194 DOI: 10.1159/000067318
Received: December 29, 2001 Accepted after revision: June 24, 2002
Yield of 5,536 Diagnostic Coronary Arteriographies: Results from a Data Registry Jan Kyst Madsen Jan Bech Erik Jørgensen Jens Kastrup Henning Kelbæk Kari Saunamäki Cardiac Catheterisation Laboratory, Heart Centre, Rigshospitalet, Copenhagen, Denmark
Key Words Coronary arteriography W Coronary artery disease W Diagnostic arteriography
Abstract The number of coronary arteriographies (CAG) has increased tremendously all over the industrialised world over the past years. Even though the potential benefit is high in patients with angina pectoris, for example, with expected life prolongation in case of three-vessel disease or left main stenosis with subsequent coronary artery bypass grafting (CABG), the indication for treatment is not as dramatic in all patients and at the same time CAG is a procedure with at least, some risk, and costs are not negligible. It is therefore pertinent, and hence also the purpose of the present analysis, to make observations on indications, clinical and angiographic findings and their combinations which could be helpful in clinical practice/decision-making. Furthermore, the purpose was to analyse the consequences of CAG with respect to revascularisations such as percutaneous transluminal coronary angioplasty (PTCA) or CABG. Copyright © 2003 S. Karger AG, Basel
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© 2002 S. Karger AG, Basel 0008–6312/02/0984–0191$18.50/0
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We have analysed data from 5,536 consecutive CAGs performed from April 1999 to September 2000 at the Rigshospitalet (n = 4,728) and the Bispebjerg Hospital, Copenhagen (n = 637), and from March 1st, 2000, at the Hillerød Hospital (n = 171). Data have been derived from an existing and ongoing data base. In connection with the CAG, previous and present heart disease, severity of possible angina, procedure-related data, results of CAG (e.g. ejection fraction, number of vessels affected and their location), treatment, and administrative data, are all registered. In the data base, coronary artery disease (CAD) is considered significant if the diameter is reduced to less than 50%. Angina pectoris is graded according to the Canadian Cardiovascular Society Classification system (CCS class 1–4), silent ischaemia is defined as STdepression during the exercise test or transient defects in scintigraphies without angina pectoris; atypical symptoms mainly describe chest pain, where either chest pain is induced by cold, physical or emotional stress or when chest pain is relieved by the use of nitroglycerin. Postinfarction ischaemia is divided into early angina or STdepression during exercise test within 1 week or late angina from 1 to 5 weeks after infarction. Unstable angina is defined as angina accompanied by ST-depression or/and elevation or by biochemical markers of ischaemia. Sixty-nine per cent of the patients were males. The median age was 61 years (range: 16–94). The indications for CAG are listed in table 1. CAG to evaluate valvular
Jan Kyst Madsen Cardiac Catheterisation Laboratory, Rigshospitalet Blegdamsvej 9, DK–2100 Copenhagen (Denmark) Tel. +45 35 45 20 17, Fax +45 35 34 27 05 E-Mail
[email protected]
Table 1. Indications for CAG at the
Cardiac Catheterisation Laboratory, Rigshospitalet (April 1, 1999 to September 15, 2000)
Diagnosis
n
%
Stable ischaemic heart disease Atypical symptoms Stable angina pectoris Silent ischaemia Acute ischaemic heart disease (total) Unstable angina pectoris AMI Before AMI (1 24 h and ! 7 days) After AMI (1 7 days) Complications (PTCA/CABG) Control after revascularisationa (PTCA/CABG) Valvular heart disease Hypertrophic cardiomyopathy Arrhythmias Heart transplantation (before transplantation evaluation and annual control) Lung disease (evaluation before transplantation) Not registered
2,885 672 2,117 96 1,416 858 151 80 327 23 377 369 15 116
52.0 12.0 38.2 1.7 26.0 15.5 2.7 1.4 5.9 0.5 6.8 6.7 0.3 2.1
179 66 90
3.2 1.2 1.6
Total
5,536
a
Results Are Divided according to Indications for CAG
Stable Ischaemic Heart Disease. The exercise test was not a prerequisite for a CAG even in stable ischaemic heart disease, and information on the results was consequently only available in 39.4% of the patients. Patients with silent ischaemia were excluded from this evaluation, as they – per definition – have an abnormal exercise test. In the remainder, the exercise test was abnormal, i.e. showed signs of ischaemia, in 764 out of 1,069 (71.5%), but far more often in patients with stable angina (78.9%) than in those with atypical symptoms (35.3%). The predictive value of a positive test was 86 and 91%, respec-
Cardiology 2002;98:191–194
100
AMI = Acute myocardial infarction. 127 (34%) had angina pectoris.
disease and electrophysiologic examinations were performed in all patients above 50 years of age and in persons below 50 years in the presence of symptoms or a history of ischaemic heart disease. All heart-transplanted patients had an annual CAG, and CAG was performed as part of the diagnostic evaluation prior to heart or lung transplantation.
192
Patients
tively, in patients with atypical symptoms and angina pectoris; in contrast, the predictive value of a negative test was rather low, only 57 and 31%, respectively. The prevalence of left main stem stenosis or three-vessel disease was 6.6 and 26.0%, respectively, in patients with angina and a positive exercise test, compared to 1.2 and 5.6%, respectively, in patients with a normal exercise test. Significant CAD was found in 67% of all patients with stable angina pectoris, however only in 28% of patients with atypical symptoms, but in 81% with typical angina pectoris. Left main stenosis was found in 6.0% of the patients with angina pectoris, and 29.3% had three-vessel disease without affection of the left main stem. Either of these entities was found in 24.4% in CCS class 1, 33.4% in CCS class 2, 43.7% in CCS class 3 and 42.4% in CCS class 4 (fig. 1a). Revascularisation was only performed in 13.1% of the patients with atypical symptoms, in contrast to 69.8% with stable angina (fig. 2). Acute Ischaemic Heart Disease. Patients with unstable angina pectoris form the majority. All patients with acute ischaemic heart disease had a high prevalence of CAD (fig. 1b) and subsequently received revascularisation (fig. 2).
Madsen/Bech/Jørgensen/Kastrup/Kelbæk/ Saunamäki
Valvular Heart Disease as the Main Indication. Of 105 patients without angina pectoris over 50 years of age with aortic stenosis as the main indication, 30 had CAD, 3 had left main stenosis, and 6 had three-vessel disease. Of 122 patients examined for other valvular heart diseases free of angina, 36 had CAD; 4 of the 36 had left main stenosis and 11 had three-vessel disease. Arrhythmia as the Main Indication. One hundred and sixteen patients had a CAG performed as a part of the examination due to arrhythmias: 110 cases of ventricular arrhythmias and almost all cases due to sustained or nonsustained ventricular tachycardia. In total, 66 (57%) had significant CAD. Of these, 29 patients were treated with PTCA, 17 with CABG, 20 ended up with medical treatment.
Discussion
Data base analysis is limited by incomplete data registration in some cases. This is counterbalanced by the fact that the data reflect everyday life and not a selected sub-
Fig. 1. a Patients with stable angina pectoris. Distribution of CAD (number of vessels affected) compared to the CCS class (n = 2,117). b Distribution of CAD (number of vessels affected) in patients with acute ischaemic heart disease (n = 1,416). AMI = Acute myocardial infarction.
Fig. 2. Consequence of angiography: revascularisation or medical treatment. AP = Angina pectoris; AMI = acute myocardial infarction.
Diagnostic Coronary Arteriography
Cardiology 2002;98:191–194
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group of patients. In contrast to most studies which cover mainly one aspect of a disease, e.g. acute myocardial infarction, unstable angina, or stable angina, the present analysis covers the use of CAG in various routine cardiac conditions. Regarding stress testing, the present analysis includes several types of tests, exercise ECG, pharmacological or exercise myocardial perfusion scintigraphy (single-photon emission computed tomography). This is a limitation, but on the other hand, this mirrors the real world. Another obvious limitation is the lack of information on how often a normal test prevented the patient from coming to a CAG. The present data actually indicate that this is a correct decision since a negative test is only ‘correct’, i.e. no coronary artery stenosis, in 57% of the patients with atypical symptoms and in 31% with angina pectoris. In patients with stable angina, the present results indicate that an exercise ECG alone is not a very valuable tool to help in deciding whether a patient should be referred to CAG. An abnormal test only changes the pretest likelihood from 81 to 91%, and a normal test is only confusing, as 69% will still have CAD compatible with previous studies of selected patients. Even more, the severity of clinical symptoms categorized according to CCS class does not help much either, as even in the group with least symptoms, 24.4% had left main stenosis or three-vessel disease, conditions with potential life prolongation following CABG. Consequently, we suggest that patients with clinical angina pectoris should be referred
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Cardiology 2002;98:191–194
for CAG for definitive diagnosis and risk stratification based on symptoms alone. In patients with atypical symptoms, the results are not so clear as it is likely that many patients with a normal test have not been referred. The results have lead to the conclusion that if an exercise ECG is abnormal, a CAG should be performed, but in case of a normal test, a CAG is less likely not to show any coronary disease. However with the least symptoms, a CAG should be performed. Acute ischaemic heart disease is becoming an increasing common indication, in particular unstable angina pectoris. In general, the patients with an acute ischaemic syndrome have a high prevalence of CAD, which is also reflected in the high prevalence of revascularisations. Valvular heart disease was the main indication in 384 patients. The proportion of patients with CAD concomitant with valvular heart disease underlines the need of CAG in these patients, and indicates the need of a widening of the indication. Cardiac arrhythmias were the main indication in 116 patients; the finding of CAD in 57% justifies the indication – however the value of revascularisation before electrophysiological examination is not fully apparent from the literature. Analysis of data from a registry such as the present is very important for several reasons: it provides information about the natural history of a disease not available from studies of selected patients, and it evaluates the use at a given time and allows change of practice accordingly.
Madsen/Bech/Jørgensen/Kastrup/Kelbæk/ Saunamäki
