Diagnostic coronary angiography is a minimally invasive method used to diagnose coronary artery disease.

It is the definitive diagnostic tool for determining the appropriate therapeutic management of coronary artery disease, either in the form of revascularization and/or the initiation of medical treatment with antiplatelet and antianginal medications, aiming both to relieve angina symptoms and to prevent a potential future myocardial infarction.

Coronary artery disease is the leading cause of death worldwide, with approximately 17,000,000 people losing their lives each year due to this condition.

Through diagnostic coronary angiography and additional accompanying diagnostic tools, such as intravascular imaging and quantitative assessment of coronary blood flow, the diagnosis of coronary artery disease is absolutely accurate, unquestionable, and allows for the precise determination of the appropriate treatment.

The method is minimally invasive and usually involves puncturing the artery in the wrist (radial artery) or the leg (femoral artery) after local anesthesia is administered (in the vast majority of cases, >99%, angiography is performed through the wrist).

With the use of ultrasound guidance, the puncture is completely accurate, while at the same time minimizing the risk of complications such as bleeding and hematoma. Furthermore, advances in the technology of the materials used have made diagnostic coronary angiography a fast, painless, and completely safe method for diagnosing coronary artery disease (the risk of complications is less than 0.1%). Performing the procedure via the wrist allows for immediate mobilization of the patient after the procedure, discharge from the hospital the same day, and the patient becomes fully functional and may return to work as early as the next day without major restrictions, even after stent implantation.

The examination lasts approximately 20 minutes, during which the coronary arteries supplying blood to the heart are visualized using fluoroscopy and selective injection of contrast dye through special catheters. With the use of additional diagnostic techniques, such as intravascular imaging and assessment of coronary physiology and blood flow, the duration may reach 60 minutes.

Diagnostic techniques during coronary angiography

  1. Intravascular imaging techniques
    With intravascular imaging techniques such as intravascular ultrasound (IVUS) and optical coherence tomography (OCT), precise qualitative and quantitative analysis of the atherosclerotic plaque causing the stenosis within the vessel is possible, including characterization of the plaque’s composition and total plaque burden, as well as anatomical severity of the stenosis by measuring the lumen area at the point of narrowing.
  2. Techniques for assessing intracoronary blood flow
    These techniques allow highly accurate determination of the impact of a stenosis on blood flow within the artery, i.e., the percentage (%) reduction in blood flow due to a particular lesion. If the reduction exceeds 20%, the stenosis is considered hemodynamically significant, causes myocardial ischemia under stress, and should usually be treated with stent implantation.

This is the most objective and accurate method for determining the degree of ischemia in the heart, with a diagnostic accuracy rate of over 95%, and is the only method that allows assessment of the degree of ischemia caused by each individual stenosis.

The most widely used and established method is fractional flow reserve (FFR), which involves the insertion of a special pressure wire beyond the site of the stenosis and intravenous administration of a medication to pharmacologically induce stress. The test lasts about 2 minutes, during which hyperemia-induced symptoms such as headache, chest burning, shortness of breath, and palpitations may occur, which resolve immediately within a few seconds after discontinuation of the medication.

In addition, this test allows for the assessment of microvascular function in the small vessels of the heart (microscopic in size – not visible with standard coronary angiography) and diagnosis of microvascular disease in patients without significant stenoses in the large arteries but with angina symptoms.
The indices evaluated include coronary flow reserve (CFR), which reflects how many times the heart can increase total blood flow to the myocardium, and the index of microcirculatory resistance (IMR).

Moreover, it is also possible to assess coronary blood flow using techniques that do not require administration of medication, performed at rest without inducing hyperemia and thus without associated symptoms (such as headache, chest burning, shortness of breath, palpitations).