Background

First performed in 1958

By Dr. Mason Sones

At Cleveland Clinic (OHIO USA)

Coronary Angiography remains clinical gold standard for determining significant CAD

INDICATIONS
A. Myocardial Infarction

Acute STEMI Post MI Cardiogenic shock Post MI Mechanical complications

B. NSTEMI Raised Troponin

New ST depression Hemodynamically unstable Sustained VT

Heart Failure Reduced LV function

Previous CABG Previous PCI (Last 6 Months)

C. UNSTABLE ANGINA \ CHRONIC STABLE ANGINA Refractory Angina (on Medical treatment) Intolerant to medical treatment

D. Abnormal Stress Test

Catogerized as high risk

ETT
ST depression 2mm Decreased BP >10mmHg with exercise

MPS
LV dilation Drop in EF of 10% > 2 territory of Ischemia High lung uptake

Development of VT

E. VENTRICULAR TACHYCARDIA Sustained polymorphic VT without obvious metabolic cause

F. LV SYSTOLIC DYSFUNCTION

EF <40% is Class-I indication to role out CAD

G. VALVULAR HEART DISEASE Patient >50 years undergoing valvular surgery to rule out CAD H. PREOPERATIVE Patients with angina or positive stress test undergoing high risk surgery.

CONTRAINDICATION A. Coagulopathy Discontinue Warfarin 12 hours before the procedure Stop heparin infusion 2 hours before procedure

B. Renal Failure Severe renal failure Moderate renal failure may require dialysis after the procedure Patient on dialysis should have LHC immediately after dialysis

C. DYE ALLERGY History of previous dye allergy Patients with H/o asthma or atopy are at increased risk

D. INFECTION Active infections is a reason to defer elective procedure

E. LABORATORY ABNORMALITIES
Severe Anemia

Hypokalemia/Hyperkalemia
Digitalis toxicity

F. DECOMPENSATED HEART FAILURE

Deferred if elective procedure

Patient should be able to lie supine

G. UNCONTROLLED HYPERTENSION Blood Pressure > 180/100 mmHg renders risk of severe bleeding at the access site

PATIENT PREPARATION
A. Informed consent

B. Pre catheterization assessment

Detailed history / Physical Examination

Peripheral pulses

Blood count / Coagulation profile

C. Medications Aspirin 325mg & Clopidogrel 300mg (if PCI planned)

Metformin stopped (Lactic acidosis)

D. Education May feel hot sensation after dye injection Some may have nausea

E.

EQUIPMENTS

All should be checked ECG monitor / defibrillator BP cuff Pulse oximetery Resuscitation equipments & Intubation tray

LEFT CORONARY ARTERY RAO Caudal View

LEFT CORONARY ARTERY LAO Cranial View

LEFT CORONARY ARTERY LAO Caudal View

LEFT CORONARY ARTERY RAO Cranial View

RIGHT CORONARY ARTERY LAO Plain View

RIGHT CORONARY ARTERY RAO Plain View

QUANTIFICATION OF CORONARY STENOSIS 1. Important to obtain at least 2 perpendicular views of the lesion. 2. Classified as severe when >70% stenosis in LAD, LCX, RCA & >50% in LMCA.

3. Fraction flow reserve & intra vascular ultrasonography also helps indentifying significant lesions.

COMPLICATIONS Death MI Stroke Coronary Artery Spasm Renal failure Emergency CABG

Arrthymias
Heart Failure

Vagal reaction Infection

Neuropathy Allergy

Coronary Artery dissection Bleeding