A coronary angiogram (or arteriogram) is an x-ray of the arteries located on the surface of the heart (the coronary arteries). This test helps the physician to see if any of the arteries are blocked, usually by fatty plaque. If so, the patient may be diagnosed with coronary artery disease (CAD).

A coronary angiogram is often conducted as part of cardiac catheterization, along with other catheter-based tests. These procedures may include measuring blood pressure, obtaining samples for diagnostic testing and a left ventriculogram.

During an angiogram, the physician injects a special dye (contrast medium) into the coronary arteries. To do that, the physician inserts a thin tube (catheter) through a blood vessel, usually in the upper thigh, and guides it all the way up to the heart. Once the catheter is in place, the physician can inject the dye through the catheter and into the coronary arteries and an x-ray can be taken.

Although the physician typically numbs the area for the catheter insertion, the patient is awake for the entire procedure. The patient receives a mild sedative before the procedure and does not ordinarily feel the movement of the catheter within the blood vessels.

Depending on what the angiogram shows, the physician may recommend treatments such as medication, a catheter-based procedure (e.g., balloon angioplasty, coronary stenting) or surgery (e.g., bypass surgery).

A coronary angiogram (or arteriogram) is one of the most accurate tests in the diagnosis of coronary artery disease (CAD), and over a million of them are conducted each year. The angiogram is used to pinpoint the location and severity of CAD. For example, it can reveal blockage in an artery due to either a buildup of plaque or abnormalities in the wall of the heart.

An angiogram is a relatively safe, though minimally invasive, test. The test may be administered if CAD is suspected because of symptoms such as:

An angiogram may also be done if the results of less invasive tests were abnormal. These tests may include:

• Electrocardiogram (EKG). An EKG is a recording of the heart’s electrical activity as a graph on a moving strip of paper. It helps to detect heart irregularities, disease and damage by measuring the heart’s rhythms and electrical impulses.
  
  
• Exercise stress test. An EKG is performed while the patient exercises in a controlled manner on a treadmill or stationary bicycle at varied speeds and elevations. The reaction of the heart during physical activity can be measured and compared with the heart’s function while at rest.
  
  
• Echocardiogram. This test uses sound waves to track the structure and function of the heart. A moving image of the patient’s beating heart is played on a monitor screen, where a physician can study the heart’s thickness, size and function. The image also shows the motion pattern and structure of the four heart valves, revealing any potential leakage regurgitation or narrowing stenosis. During this test, a Doppler ultrasound may also be done to evaluate blood flow and measure the severity of any regurgitation and/or stenosis.
  
  
• Nuclear stress test. A type of stress test that involves the injection of a small, harmless amount of a substance with special radionuclide properties, such as thallium. The rays emitted from this substance while in the heart allow a gamma camera to create images of the heart before, during and after physical exercise.

In patients with previous coronary artery bypass surgery, angiography of the grafts can detect any blockage or other abnormalities of these grafts.

Before the day of the coronary angiogram, patients should discuss their medical history with the physician and inform him or her of any medications currently being taken. Certain medications may need to be stopped or reduced. It is also recommended that patients with diabetes consult with a physician regarding food and insulin intake, because people are generally ordered not to eat or drink anything after midnight before the test. Individuals should talk with their physician if they have a blood-clotting disorder or an allergic reaction to any of the following:

Angiograms are typically completed as an outpatient procedure, meaning the patient is not required to stay overnight. On the day of the procedure, the patient will be admitted to the hospital or outpatient clinic.  A nurse or physician will explain the procedure and recovery. At this time, the patient and any family members will have an opportunity to ask questions about the angiogram.

The procedure will begin with the physician inserting an intravenous (IV) line into the patient’s arm. The IV allows the physician to give the patient a sedative and other necessary medications during the procedure. Small devices (electrodes) will be taped to the patient’s body, which allow the physician to monitor the heart rate.

The physician typically uses the groin or upper thigh area as the place to insert the catheter on its way to the heart, but some physicians may choose to begin at the arm or wrist. Whichever area is chosen will then be cleaned, shaved and numbed with a local anesthetic. The catheter is then fed through the artery in that area (e.g., the femoral artery in the groin or upper thigh) and up into the heart. There may be some minor discomfort during this period.

When the catheter reaches the target area, the dye is injected through the catheter and into a coronary artery. This dye will allow the physician to clearly see the coronary arteries on the angiogram. The patient may feel hot and flushed for about 10 seconds as the dye is administered. Patients may also be asked by the physician to take certain actions, such as coughing or deep breaths, to help the dye travel through the coronary arteries. During this time, still or moving angiograms are taken to record the test results.

The dye is easily visible to the physician monitoring the angiogram images. A “shadow” cast by the dye will show blockages of the arteries and abnormal motions of the heart walls. In the case of diseased arteries, for example, arterial walls may appear to be abnormally narrow or irregularly shaped.

Once the angiogram is completed, the catheter is removed from the body and the hole is sealed with a plug inserted under the skin or with pressure placed on the point of catheter entry. Stitches may also be necessary if the point of catheter insertion was in the elbow area. The entire process of taking angiograms lasts approximately 20 to 30 minutes, or a total of 1.5 hours from pre-procedural preparation to the removal of the catheter.

Other procedures such as angioplasty and stent placement can be performed during the same setting based on the finding of the diagnostic study and the feasibility of such intervention in a given patient.

After the coronary angiogram, the patient will return to a hospital bed for recovery. He or she will likely feel groggy from the sedative. The patient will lie in bed with legs straight for several hours and be discharged two to eight hours after the procedure. The sedative will have worn off and the catheter insertion point may be bruised and sore. It is highly recommended that patients drink extra fluids during this period of rest. Throughout the post-catheterization monitoring, the point of catheter entrance will be checked for bleeding, swelling or infection.

Patients will be given instructions from their physician that will address the following:

• Exercise and exertion. Patients are reminded to refrain from lifting heavy objects and engaging in strenuous exercise or sexual activity for several days after the procedure.
  
  
• Care of the incision area. Bruising and soreness is possible and normal. Severe pain or swelling may require medical attention.
  
  
• The type and use of medications for pain or as treatment for conditions found on the angiogram.

While there are some risks involved in any invasive or minimally invasive procedure, coronary angiograms are widely used and complications are low, occurring in less than three percent of patients. These potential complications include:

• Bleeding in the area of the catheter insertion
• Abnormal heart rhythms arrhythmias
• Infection
• Allergic reaction to the dye
• Damage to the arteries
• Heart attack
• Stroke
• Air embolism (when air gets into the bloodstream, where it could cause damage)
• Death

The risk of complications is greater if people are over the age of 70, or have conditions such as diabetes, hardening of the arteries (atherosclerosis), kidney failure or carotid artery disease.

Based on the nature and extent of the condition, the physician will use the results of the angiogram to determine the most appropriate treatments, which may include:

• Coronary bypass surgery. A procedure in which a segment of a blood vessel from another part of the body (usually the leg) is used to reroute blood flow around a clogged artery supplying blood to the heart. If there are two, three, four or five clogged arteries, the situation may call for a double, triple, quadruple or quintuple bypass.

Magnetic resonance angiogram (MRA) has evolved to a very sophisticated level, such that blood flow through the coronary (heart) or carotid (neck) arteries can be viewed without the use of catheter-based techniques, such as coronary angiograms.

Instead, the noninvasive MRA scan takes three-dimensional images of the blood flow, so the physician can detect any damage to the vessel walls. It can also reveal blockage or re-narrowing (restenosis) after vein graft procedures.

The test takes less time than an angiogram, requires less of a recovery period and does not entail the same risks as a more invasive procedure. As a result, MRA may eventually become an alternative to angiography for some patients, and may even become a screening tool for the detection of atherosclerosis and heart disease in their earliest stages.

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor or heathcare professional the following questions related to a coronary angiogram:

1. Why are you recommending a coronary angiogram for me?
   
   
2. What do you hope to learn from the angiogram?
   
   
3. What results would indicate a problem with my arteries?
   
   
4. Where will I have the test done and by whom?
   
   
5. What are the risks involved with this procedure?
   
   
6. Will I receive any other tests at the same time?
   
   
7. When and from whom will I receive the results?
   
   
8. What will likely follow if my angiogram shows blockage?
   
   
9. How often will I need to have coronary angiograms?
   
   
10. Am I a candidate for a less invasive angiography?