Repeat Coronary Angiography in Patients Aged over 50 Years with Previously Normal/Non-Obstructive Coronary Angiogram-Insights from a Retrospective Study

Abstract

(1) Introduction: A significant proportion of patients undergoing coronary angiography (CAG) have normal (NCA) or non-obstructive coronary artery disease (NOCAD). This study retrospectively tested the incidence of re-catheterization, and long-term outcomes of this population in patients aged over 50 years. (2) Methods: We identified all patients above 50 years of age with NOCAD who underwent their first CAG at our center between January 2008 and December 2019. Patients were evaluated for their baseline characteristics, risk factors profile, and indication for CAG. Patients undergoing repeat CAG after the index procedure were assessed for the above, including the primary preventive pharmacotherapy prescribed. (3) Results: A total of 1939 patients were reported to have NOCAD. Of these, 1756 (90%) patients (62% males, median age 66 (56-75) years) had no repeat angiography (group 1). Repeat angiography was performed in 10%: 136 (7%) proved futile (median time for repeat angiography 5 (3-8) years) (group 3), and 47 (3%) ended with angioplasty (median time for repeat angiography 4 (3-6) years) (group 2). Male gender, BMI above 30 (23% vs. 13%), hypertension (68% vs. 57%), diabetes (28% vs. 17%) and smoking (36% vs. 19%) were significantly higher in the interventional group. Regression analysis showed both paroxysmal atrial fibrillation and hyperlipidemia were significantly associated with repeat CAG. The indication for the first CAG was mainly symptoms related. In the interventional repeat angiography (n = 47) the incidence of troponin positive cases increased from 8.2% before intervention to 57.5%, 50% being ST elevation cases. The symptoms-related cases went from 36.7% to 18.4%. Intriguingly, 85% of the interventional group were not prescribed statin and/or aspirin on a regular basis, and/or did not adhere to treatment. (4) Conclusions: NOCAD is a frequent occurrence. The threshold for repeat angiography must be higher, better reserved to troponin positive cases. Moreover, patients must be handled according to their risk profile, not being mistakenly reassured by a snapshot benign coronary angiography.

Keywords: atherosclerosis; atherothrombosis; myocardial infarction; non-significant coronary disease; normal angiogram.

Figure 1

The cumulative annual occurrence of repeat CAG in groups 2 and 3. Group 2—repeat interventional angiography, Group 3—repeat non-interventional angiography.

Figure 2

The distribution of each indication for the first angiography in the study groups. CAG—coronary angiography, CP—chest pain, WMA—wall motion abnormalities, AV—aortic valve, MV—mitral valve, Scan—thallium scan, CCT—coronary CT, CPR—cardiopulmonary resuscitation.

Figure 3

The differences in the indications between the first CAG and the repeat CAG in the repeat non-interventional and interventional subgroups, respectively. CP—chest pain, Trop—troponin.