Interventional cardiology

Normal angiography but adverse outcomes: how to manage the paradox?

Follow-up pathways are needed for patients who have ‘normal’ coronary angiography to help manage ongoing symptoms and adverse psychological outcomes, a leading cardiologist says.

Many patients who have no obstructive coronary artery disease found on angiography paradoxically have worse health status afterwards than those who have obstructive disease and undergo treatment, according to Professor John Beltrane, a cardiologist and Head of the Discipline of Medicine at The Queen Elizabeth Hospital, Adelaide.

Writing in the European Heart Journal, he says health status assessments should form part of the routine follow up of the 60% of patients who have a ‘normal’ angiogram’ to help guide subsequent evaluations and psychological support.

The recommendation is based on findings from a study of 459 patients who underwent elective angiography. When followed up at six and 12 months, greater improvements in health status and anxiety scores were seen among the 38% of patients diagnosed with obstructive coronary artery disease than the 62% who had normal angiograms.

The findings suggest that a normal result may not provide long term reassurance, particular if a patient continues to have symptoms, according to Professor Beltrane and co-author Dr Rosanna Travella (PhD).

Further investigations such as coronary haemodynamic studies may be warranted, they propose, because some patients may have an ischaemic basis for their chest pain via mechanisms such as abnormal coronary vascular resistance or endothelial dysfunction.

“An angiogram that does reveal cardiac disease may also perpetuate the patient’s  anxiety as there is no explanation for symptoms or pathway for intervention,” they note.

Health status assessments may therefore have value by revealing psychopathological disorders, which should not be dismissed as ‘soft’ outcomes because they are associated with increased healthcare utilisation and poor prognosis, they say.

“Measuring symptom burden, functional capacity and physical and mental quality of life allows for informed clinical decisions.

“The health status trajectories should be considered as part of any evaluation of prescribed therapies. For example, if improvements in chest pain symptoms over time do not correlate with improvements in quality of life, then examination for psychological conditions may be considered.”

However, Professor Beltrane says there is a long way to go before health status assessment are incorporated into routine care of patients undergoing angiography.

“ The finding of normal angiography may be viewed as a paradox, in that the knowledge of no coronary disease on one hand provides comfort, but for the patient it can also be what causes the most anxiety. For clinicians, it presents a very real challenge but at the same time, an important opportunity to drive efforts in establishing a foundation for further evaluation of these patients where quantifying, interpreting, and managing health status is at the core.”

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