PR O GRE S S I N C ARDI O VAS CU L AR D I S EAS E S 5 5 ( 2 0 13 ) 50 45 08

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Coronary Angiography Is the Gold Standard for Patients with

Significant Left Ventricular Dysfunction

Michael J. Lima , Christopher J. Whiteb, c,

a
Saint Louis University School of Medicine, Saint Louis, MO, USA
b
The Ochsner Clinical School, University of Queensland, Australia
c
John Ochsner Heart and Vascular Institute, Ochsner Medical Institutions, New Orleans, LA, USA

A R T I C LE I N FO AB S T R A C T

Keywords: Left ventricular (LV) dysfunction has been shown to be significantly related to ongoing
Invasive coronary angiography myocardial ischemia, hibernation, and thus, coronary artery disease. Current treatments
Cardiomyopathy for patients with LV dysfunction and concomitant coronary artery disease center around
Revascularization the potential benefit of coronary revascularization, in the form of either coronary artery
bypass grafting surgery (CABG) or percutaneous coronary intervention (PCI). Given the great
diversity in the patient population making up those with LV dysfunction and coronary
artery disease, intense interest has been directed in determining which patients benefit the
most from revascularization. Multiple noninvasive evaluations have been utilized in order
to select or stratify these patients. However, the gold standard by which clinicians make
revascularization determinations is invasive coronary angiography. Within this review, we
compare and contrast the noninvasive modalities available to the present day clinician
with invasive angiography. Furthermore, we outline the ways in which invasive
angiography has been utilized in patients with LV dysfunction and summarize the present
guidelines regarding its usefulness.
2013 Elsevier Inc. All rights reserved.

This issue of Progress in Cardiovascular Diseases focuses on left
ventricular (LV) dysfunction. While mortality from acute
myocardial infarction has decreased significantly over the
past decades, the incidence of coronary artery disease has not
seen a similar decline. Not surprisingly, the concomitant
increase in congestive heart failure (CHF) can easily be
attributed to these trends. Gheorghiade and Bonow1 found
that 68% of CHF patients randomized were defined as having
coronary artery disease (CAD) in the 13 randomized multi-
center trials published in the New England Journal of Medicine
from 1986 to 1997. The pathophysiologies leading to LV
dysfunction, CHF, and worsening LV function are all inter-
related with myocardial ischemia resulting from decreased
coronary blood flow being at the core of the equation.
Unfortunately, the patient manifestations of combined CAD
and LV dysfunction are not homogeneous and this has
created a wide variety of seemingly conflicting data from
clinical trials addressing best treatment approaches. Given
the heterogeneity of patients with LV dysfunction and
evidence supporting various medical, percutaneous, and
surgical therapies, it remains difficult to make specific
conclusions regarding the overall best treatment for patients
with left ventricular dysfunction. However, a consistent
theme, that has stood the test of time in the management of

Statement of Conflict of Interest: see page 508.

Address reprint requests to Christopher J. White, MD, FSCAI, FACC, FAHA, FESC, John Ochsner Heart & Vascular Institute, Ochsner Medical
Institutions, 1514 Jefferson Highway, New Orleans, LA 70121.
E-mail address: drcjwhite@gmail.com (C.J. White).

0033-0620/$ see front matter 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.pcad.2013.01.003
 PR O G RE S S I N C ARDI O V A S CU L A R D I S EA S E S 5 5 (2 0 1 3) 50 45 0 8
Abbreviations and Acronyms LV dysfunction, has
been the utilization of
CABG = coronary artery bypass
coronary angiography
surgery
to identify the pres-
CAD = coronary artery disease ence of significant cor-
onary artery disease to
CHF = congestive heart failure
guide therapies. We
CTA = computerized tomo- will focus on outlining
graphic angiography the applicability of cor-
onary angiography in
LV = left ventricular
this patient subset
PCI = percutaneous coronary
within this review.
intervention
Diagnosis of coronary artery disease
The role of coronary artery disease and its association with
ongoing chronic myocardial ischemia and or hibernating
myocardium in patients with decreased LV function has
been outlined already in this issue. The principal question
that we address here is what is the optimal modality for
determining a specific etiology and best treatment of LV
dysfunction in any given patient?
There is an extensive literature that has evaluated
multiple testing strategies as to their ability to detect the
presence of coronary artery diseasesome by inferring that
coronary disease must be present if there are inducible
changes in regional wall motion with stress and others that
rely on evaluating relative myocardial perfusion at rest and
stress. These investigations have focused on the correlation
between noninvasive testing and coronary angiography.
Invasive angiography has dramatically progressed since the
pioneering days of Dr. Mason Sones when it was performed by
nonselective injection of contrast into the aorta. Catheteriza-
tion laboratories have become widely available extending
from academic centers to community hospitals. Although an
invasive procedure, the overall risk for cardiac catheterization
and coronary angiography was evaluated during the 1990s
and found to be consistently low (Table 1). More recently,
angiographers have continued to refine their techniques with
much smaller diameter catheters (84 French) and using the
safer radial artery (versus the femoral artery) as a point of
vascular access. Both of these advancements have decreased
complications of the procedure, particular the bleeding and
vascular complications.2,3
Noninvasive techniques to detect coronary artery disease
include the following: (1) exercise electrocardiography, (2)
stress echocardiography, (3) nuclear stress imaging, (4)
cardiac magnetic resonance angiography, and (5) computer-
ized tomographic angiography (CTA). The European Society of
Cardiology's, expert writing group has compared the relative
advantages of the noninvasive testing strategies with coro-
nary angiography (Table 2). While the writing group separated
the ability of each test to look at specific pathophysiologic
aspects of patients with LV dysfunction, the detection of
coronary artery disease has been extensively studied for each
modality. As can be seen in Table 3, the sensitivity and
specificity of each modality range from 61% for exercise
505
Table 1 Risk of cardiac catheterization and coronary
angiography.
Complication %
Mortality 0.11
Myocardial infarction 0.05
Cerebrovascular accident 0.07
Arrhythmia 0.38
Vascular complications 0.43
Contrast reaction 0.37
Hemodynamic complications 0.26
Perforation of heart chamber 0.03
Other complications 0.28
Total major complications 1.70
From Scanlon PJ, Faxon DP, Audet AM et al. ACC/AHA guidelines for
coronary angiography: a report of the American College of
Cardiology/American Heart Association Task Force on Practice
Guidelines (Committee on Coronary Angiography). J Am Coll Cardiol
1999; 33:1760.
electrocardiography to 99% for CTA, indicating that high-
quality testing in ideal patients can result in accurate
detection of coronary disease.
Computerized tomographic angiography (CTA)
The ability of CT imaging technology to noninvasively image
the coronary arteries has undergone significant advances and
has gained wide clinical availability and clinical usefulness.
Ghostine et al.5 examined 93 consecutive patients in sinus
rhythm with a dilated cardiomyopathy for the presence of
coronary artery disease, comparing 64 slice CTA to invasive
angiography. This comparison yielded an overall accuracy of
CTA of 96%, with a positive predictive value of 97% (using a
threshold of a > 50% coronary stenosis to define CAD).
However, despite inclusion criteria to select for ideal patients
to undergo CTA imaging, heavily calcified or blurred images
(low quality) were found in 26 of the 93 patients. Furthermore,
there was a significant correlation between slower heart rates
and good image quality. In order to achieve optimal heart
rates, patients with LV dysfunction must be well compensat-
ed from a heart failure standpoint to tolerate additional beta-
blockade during or immediately prior to the imaging proce-
dure. The inability to tolerate such aggressive pharmacologic
heart rate lowering limits the overall number of patients who
may benefit from CTA imaging.
A meta-analysis of six separate studies (comprising 452
patients) revealed a sensitivity of 98% and specificity of 97%
for CTA in discriminating ischemic vs. nonischemic cardio-
myopathy as compared to invasive angiography.6 In total, it
was reported that up to 3% of the imaged segments were non-
interpretable due to artifact or calcification. Interestingly, the
radiation dose for the CTA was reported in the four studies
that utilized 64-slice technology and found that the dose
ranged from 10 5 mSv to 28 5 mSv. Table 4 summarizes the
dose estimates for cardiac studies as reported in the ACCF/
ACR/AHA/NASCI/SAIP/SCAI/SCCT 2010 Expert Consensus
Document on Coronary Computed Tomographic Angiography.7
While these data are somewhat dated, in that 256-slice
506 PR O GRE S S I N C ARDI O VAS CU L AR D I S EAS E S 5 5 ( 2 0 13 ) 50 45 08

Table 2 Comparison of testing modalities in patients with congestive heart failure for detection of coronary artery disease.
CAD Detection Echo CMR Cath SPECT MDCT PET

Ischemia +++(a) +++ +++(b) +++ +++

Hibernation +++(a) +++(a) +++ +++
Scar ++ +++ ++ ++
Coronary +++ +++
Anatomy
Main Widely available, Good quality Good Good High quality Good image
advantages portable, images, no radiation availability availability images quality
no radiation,
relatively
low cost
Main Dependent Limited availability, Radiation, Radiation Radiation, image Radiation,
disadvantages on image multiple invasive quality limited Limited
quality contraindications, in patients with availability
Quality limited in arrhythmia
patients with
arrhythmia

Adapted from McMurray et al.4

dual-source CT technology is now available and radiation
exposure continues to be further decreased by changes in
gating, they represent the technology most widely available
presently. Additionally, clinicians must be mindful of the
additive radiation doses in multiple tests obtained during a
patient's work-up and treatment. In addition to radiation
exposure, the high incidence of chronic kidney disease and
atrial fibrillation will continue to limit the usefulness of CTA
in patients with decreased LV function.
Historical studies establishing coronary
angiography and treatment decision making
Multiple studies from the 1980s have guided cardiac care,
especially decisions to perform revascularization for patients
with coronary artery disease that continue today.810 In the
Veterans Administration Coronary Artery Bypass Surgery
Cooperative Study, it was shown that the most profound
benefit occurred in high angiographic risk subgroup that
received CABG. This group was defined as having three-vessel
coronary disease and LV dysfunction. In the similar European
Coronary Surgery Study, the inclusion criteria stated that
subjects were required to have an angiographic obstruction of
at least 50% in two or more major coronary arteries. The
landmark Coronary Artery Surgery Study evaluated the
relationship between angiographic coronary artery disease,
LV dysfunction, and decreased survival in medically treated
patients. While these trials may be criticized for not
representing contemporary cardiovascular medicine, they
nonetheless established coronary angiography as the hall-
mark for determining the presence of coronary artery disease
and, as such, dictated that most patients with severe
angiographic coronary disease and left ventricular dysfunc-
tion were preferentially treated with CABG for over 20 years.
Furthermore, they established the practice of CABG (driven by
angiographic determination of lesion significance) as a
preferred treatment for patients with LV dysfunction.
The Surgical Treatment for Ischemic Heart Failure
(STICH) trial
The STICH trial11 is the most recent look into refining the
hypothesis surrounding revascularization for coronary artery

Table 3 Diagnostic accuracy of noninvasive testing for Table 4 Representative values and ranges of effective
coronary artery disease. radiation dose for cardiac studies.
Test Sensitivity Specificity Effective Dose Range
Examination (mSv) (mSv)
Exercise ECG 61% 70%77%
Echo Chest X-ray (PA and lateral) 0.1 0.050.24
Exercise 70%85% 77%89% Diagnostic invasive angiogram 7 216
Pharmacologic 85%90% 89%90% 64-Slice coronary CTA
SPECT Without tube current modulation 15 1218
Exercise 82%88% 70%88% With tube current modulation 9 818
Pharmacologic 88%91% 75%90% Myocardial perfusion study
Cardiac magnetic resonance Sestamibi (1-day) stress/rest 12 N/A
Dobutamine 83% 86% Thallium stress/redistribution 29 N/A
Vasodilator 91% 81% Myocardial viability study
64-Slice CTA 93%97% 80%90% Thallium stress/reinjection 41 N/A

Adapted from SIHD Guidelines (in press, forthcoming). Adapted from Mark et al.7
 PR O G RE S S I N C ARDI O V A S CU L A R D I S EA S E S 5 5 (2 0 1 3) 50 45 0 8 507

Table 5 Coronary angiography recommendations from
the 2009 ACC/AHA focused update on the diagnosis and
management of heart failure.
Class Recommendation
I Coronary angiography should be performed in patients
presenting with heart failure who have angina or
significant ischemia unless the patient is not eligible for
revascularization of any kind. (Level of Evidence B)
IIa Coronary angiography is reasonable for patients presenting
with heart failure who have chest pain that may or may not
be of cardiac origin who have not had evaluation of their
coronary anatomy and who have no contraindications to
coronary revascularization. (Level of Evidence C)
IIa Coronary angiography is reasonable for patients presenting
with heart failure who have known or suspected coronary
artery disease but who do not have angina unless the
patient is not eligible for revascularization of any kind.
(Level of Evidence C)
disease as the central treatment for patients with concomi-
tant left ventricular dysfunction. Care must be taken to
evaluate the methodology of the study12 with respect to how
patients were evaluated prior to randomization before ex-
trapolating its results. While subjects underwent extensive
evaluation with noninvasive testing to evaluate myocardial
viability and functional capacity, the cornerstone for entry
into the study was invasive coronary angiography. There was
explicit exclusion of any patient deemed to have a left main
stenosis of more than 50% by coronary angiography. Likewise,
the definition of a significant coronary artery stenosis
remained an angiographic narrowing present within the
vessel. In this way, this contemporary trial shows us that we
have not progressed from the time of Coronary Artery Surgery
Study in utilizing angiography for defining significant coro-
nary artery disease. While the results of the study did not
show a significant benefit of CABG over medical therapy for
all-cause mortality, patients with three-vessel CAD or a 75%
proximal LAD narrowing had better outcomes with CABG.
The trial protocol was changed multiple times, as the
investigators loosened the original mandate for SPECT viabil-
ity assessment to allow for other noninvasive means of
assessing viability. At the end of enrollment, 19% of the
enrolled patients did not have any noninvasive viability
assessment, as it became strongly suggested it was not a
requirement. Given the variability within the noninvasive
testing within this patient population, it would be very
difficult to analyze these patients in a meaningful way that
would elevate the importance of any noninvasive study to
guide the treatment of similar patient above that of the
coronary angiogram. In fact, further evidence of the perceived
strength of coronary angiography in the modern cardiovas-
cular practitioners mind can be seen by observing that 17% of
the patients who were randomized to the medical therapy
arm of the study received CABG anyway.
Guidelines and appropriate use criteria
There are three recent documents that combine expert
opinion and clinical evidence to support the role of invasive
coronary angiography in patients with LV dysfunction. The
first is the 2009 Focused Update Incorporated Into the
American College of Cardiology/American Heart Association
2005 Guidelines for the Diagnosis and Management of Heart
Failure in Adults12 and the recommendations related to
coronary angiography are summarized in Table 5. These
recommendations are weighted toward using angiography
for patients with angina and especially mindful of the
patient's ability to undergo revascularization. The 2012
Appropriate Use Criteria for Diagnostic Catheterization
document13 also addresses the role that coronary angiogra-
phy may play in the care of the patient with depressed LV
function (Table 6). Interestingly, these recommendations are
similar to the Heart Failure Guidelines in that patient
symptoms are given a great deal of weight. This document
also endorsed (as appropriate) the role of coronary angiogra-
phy to diagnose and/or evaluate patients with reduced LV
function for those with a new diagnosis or in patients with
worsening status.
Most recently, the European Society of Cardiology has
released its guidelines for the diagnosis and treatment of
heart failure.14 The writing group confirmed that coronary
angiography was necessary in patients with angina or a
history of cardiac arrest if suitability for revascularization
needed to be established. Furthermore, angiography was
recommended to follow-up noninvasive findings of reversible
ischemia and/or viability. These statements are consistent

Table 6 2012 Appropriate use criteria for diagnostic catheterizationsummary of criteria related to patients with
decreased left ventricular function appropriate use score.13,510
Category Indication Asymptomatic Symptomatic

Suspected CAD with prior Baseline resting LV dysfunction (LVEF 40%) and evidence of myocardial A (7) A (8)
noninvasive testing viability in dysfunctional segment
Newly recognized LV systolic dysfunction (LVEF 40%) with an U (6) A (8)
unknown etiology
Newly recognized LV systolic dysfunction (LVEF 41%49%) with an U (5) A (8)
unknown etiology
Cardiomyopathies Known or suspected cardiomyopathy with or without heart failure A (7)
Re-evaluation of known cardiomyopathychange in clinical status or A (7)
cardiac exam or to guide therapy
508 PR O GRE S S I N C ARDI O VAS CU L AR D I S EAS E S 5 5 ( 2 0 13 ) 50 45 08
with the previous recommendations by the American College
of Cardiology/American Heart Association.
Taken as a whole, the evidence strongly supports the role
of invasive coronary angiography in patients with LV dys-
function who also have: symptomatic angina pectoris, ische-
mia on noninvasive studies, and/or viability on noninvasive
studies and who are candidates for revascularization.
Invasive coronary angiography: summary
While there is no single best way to evaluate patients with
decreased LV function, the role of invasive coronary angiog-
raphy clearly remains highly relevant in the present era of
multiple noninvasive cardiac imaging modalities. First and
foremost, invasive angiography remains the gold standard
by which the presence and severity of coronary artery disease
is defined. Additionally, catheterization laboratories and
skilled operators are widely available, making high-quality
and extremely safe coronary angiography readily available.
Statement of Conflict of Interest
All authors declare that there are no conflict of interest.
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