Percutaneous Transluminal Coronary Angioplasty: A Literature Review and Ratings of Appropriateness and Necessity
Dec 31, 1990
This report contains a literature review of coronary angiography, a comprehensive set of indications for performing this procedure, and ratings of the appropriateness and necessity for each indication. It primarily concentrates on coronary angiography studies; however, studies examining percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG) surgery are also included to establish the efficacy of coronary angiography in coronary artery disease patients. Findings show that where significant coronary artery disease is defined as a 50 percent reduction in luminal diameter, coronary artery disease occurred in almost 80 percent of patients sampled; with a 70 percent reduction in luminal diameter, there was 72 percent occurrence. Using either criterion, significant left main or three-vessel coronary artery disease was present in approximately 35 percent of procedures sampled. Data on complications associated with coronary angiography show that patients with left main coronary artery disease have a threefold greater risk of myocardial infarction and sevenfold greater risk of death. Other complications include cerebrovascular accidents (0.07%), ventricular arrhythmias (0.47%), local vascular injury (0.59%), and contrast dye reactions (0.23%). The average myocardial infarction rate was 0.07% and the average mortality rate was 0.10% for 1981-1989. The authors draw conclusions concerning the efficacy of coronary angiography for nine specific clinical conditions, based on a comparison of CABG surgery, medical therapy, and observational studies of PTCA: Coronary angiography is efficacious for patients with both chronic stable angina and unstable angina, whose angina cannot be satisfactorily controlled by medical therapy; evidence supports the efficacy of coronary angiography in acute myocardial infarction patients who experience cardiogenic shock or an evolving myocardial infarction, and in myocardial infarction survivors who experience angina or have evidence of myocardial ischemia; following revascularization, the only patients shown to clearly benefit from coronary angiography are those who develop severe angina; there are no studies on the efficacy of coronary angiography in survivors of sudden cardiac death without angina; there are conflicting data on efficacy with patients with chest pain of uncertain origin; and there are no data to support efficacy of coronary angiography in patients with ventricular arrhythmias, or in asymptomatic patients.