Diagnostic cardiac catheterization and coronary angiography are considered the gold standard in the assessment of the anatomy and physiology of the heart and its associated vasculature. In 1929, Forssmann demonstrated the feasibility of cardiac catheterization in humans when he passed a urological catheter from a vein in his arm to his right atrium and documented the catheter's position in the heart by x-ray. In the 1940s, Cournand and Richards applied this technique to patients with cardiovascular disease to evaluate cardiac function.These three physicians were awarded the Nobel Prize in 1956. In 1958, Sones inadvertently performed the first selective coronary angiography when a catheter in the left ventricle slipped back across the aortic valve, engaged the right coronary artery, and power-injected 40 mL of contrast down the vessel. The resulting angiogram provided superb anatomic detail of the artery, and the patient suffered no adverse effects. Sones went on to develop selective coronary catheters, which were modified further by Judkins, who developed preformed catheters and allowed coronary artery angiography to gain widespread use as a diagnostic tool. In the United States, cardiac catheterization is the second most common operative procedure, with nearly three million procedures performed annually.
Indications, Risks, and Preprocedure Management
Cardiac catheterization and coronary angiography are indicated to evaluate the extent and severity of cardiac disease in symptomatic patients and to determine if medical, surgical, or catheter-based interventions are warranted (Table 230-1). They are also used to exclude severe disease in symptomatic patients with equivocal findings on noninvasive studies and in patients with chest-pain syndromes of unclear etiology for whom a definitive diagnosis is necessary for management. Cardiac catheterization is not mandatory prior to cardiac surgery in some younger patients who have congenital or valvular heart disease that is well defined by noninvasive imaging and who do not have symptoms or risk factors that suggest concomitant coronary artery disease.
Table 230–1. Indications for Cardiac Catheterization and Coronary Angiography |Favorite Table|Download (.pdf)
Table 230–1. Indications for Cardiac Catheterization and Coronary Angiography
|Coronary Artery Disease|
|Asymptomatic or Symptomatic|
|High risk for adverse outcome based on noninvasive testing|
|Sudden cardiac death|
|Sustained (>30 sc) monomorphic ventricular tachycardia|
|Nonsustained (<30 sc) polymorphic ventricular tachycardia|
|Canadian Cardiology Society class III or IV angina on medical therapy|
|Unstable angina—high or intermediate risk|
|Chest-pain syndrome of unclear etiology and equivocal findings on noninvasive tests|
|Acute Myocardial Infarction|
|Reperfusion with primary percutaneous coronary intervention|
|Persistent or recurrent ischemia|
|Severe pulmonary edema|
|Cardiogenic shock or hemodynamic instability|
|Mechanical complications—mitral regurgitation, ventricular septal defect|
|Valvular Heart Disease|
|Suspected valve disease in symptomatic patients—dyspnea, angina, heart failure, syncope|
|Infective endocarditis with coronary embolization|
|Asymptomatic patients with aortic regurgitation and cardiac enlargement or ↓ ejection fraction|
|Prevalve surgery in older patients with coronary artery diseaserisk factors|
|Congestive Heart Failure|
|New onset with angina or suspected undiagnosed coronary artery disease|
|Congenital Heart Disease|
|Prior to surgical correction, when symptoms or noninvasive ...|
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