Coronary Angiography in India and UAE | Complete Patient Guide

• ELIGIBLE PATIENTS:

• Patients with stable angina (CCS Class II–IV) unresponsive to optimal medical therapy (beta-blockers, long-acting nitrates, ranolazine, ivabradine)

• Patients with a positive or equivocal non-invasive stress test: exercise ECG, stress echocardiography, nuclear myocardial perfusion imaging (SPECT/PET), or cardiac MRI with adenosine stress perfusion

• Patients with acute coronary syndrome (NSTEMI/UA with GRACE score >140 or high-risk features; STEMI requiring primary PCI within 90 minutes of first medical contact)

• Patients with new-onset heart failure or reduced LVEF (<40%) of suspected ischemic aetiology, requiring viability assessment

• Pre-operative evaluation for valvular heart surgery, TAVR candidacy assessment, or heart transplant workup

• Patients with inconclusive CT coronary angiography (CTCA) findings, significant calcium scoring (Agatston score >400), or known renal insufficiency limiting contrast CT

• Patients with anomalous coronary origins suspected on echocardiography or CT

• Survivors of sudden cardiac arrest with suspected obstructive CAD

• REQUIRED PRE-PROCEDURE DIAGNOSTICS:

• 12-lead ECG and 24-hour Holter monitoring

• Echocardiogram (2D/3D TTE) to assess LV function, wall motion, valve morphology, and pericardial status

• Full blood panel: CBC, renal function (eGFR, serum creatinine), liver function tests, coagulation profile (PT-INR, aPTT), fasting lipid panel, HbA1c, thyroid function

• Point-of-care troponin I or T (high-sensitivity) if ACS suspected

• Chest X-ray (PA and lateral)

• Optional: CT coronary angiography (CTCA) with calcium scoring for risk stratification

• Optional: Nuclear stress test (SPECT/PET) or stress cardiac MRI for functional ischemia quantification

• RELATIVE CONTRAINDICATIONS:

• Severe uncorrected contrast allergy (pre-medication protocol with corticosteroids and antihistamines required; iso-osmolar contrast agents preferred)

• Acute renal failure or severe chronic kidney disease (eGFR <30 mL/min/1.73m²) — CO2 angiography or IVUS-guided PCI considered as alternatives

• Uncontrolled coagulopathy or active systemic hemorrhage (INR >2.5 without reversibility)

• Uncompensated congestive heart failure or hemodynamic instability requiring stabilisation prior to elective procedure

• Active febrile illness or systemic infection

• Severe uncontrolled hypertension (SBP >180 mmHg) — requires pre-procedure medical optimisation

• Pregnancy (relative — radiation risk; defer if possible or use radiation-minimising protocols)

STANDARD DIAGNOSTIC CORONARY ANGIOGRAPHY (TRANSRADIAL ACCESS — PREFERRED):

The transradial approach has become the global standard of care (endorsed in ESC 2023 guidelines) due to significantly lower access-site bleeding, earlier ambulation, and reduced 30-day mortality compared to transfemoral access. A 5 Fr or 6 Fr sheath is placed in the radial artery following Allen's test or plethysmography to confirm dual-hand perfusion. Universal catheters (e.g., Tiger, Jacky, Barbeau) or dedicated left/right Judkins shapes are used. Total fluoroscopy time is typically 5–12 minutes; total procedure time 20–45 minutes. Patients are discharged the same day or after one overnight stay.

TRANSFEMORAL ACCESS (WHEN CLINICALLY INDICATED):

Reserved for cases of radial artery spasm, anomalous anatomy, failed radial access, or need for larger-bore sheaths (e.g., 7–8 Fr for rotational atherectomy or IABP insertion). Femoral puncture is performed under fluoroscopic or ultrasound guidance to target the common femoral artery at the mid-head of femur. Vascular closure devices (Angioseal, Perclose ProGlide, MANTA for large-bore) reduce time to haemostasis and allow earlier ambulation.

FUNCTIONAL HAEMODYNAMIC ASSESSMENT (ADJUNCTIVE — SAME SESSION):

• Fractional Flow Reserve (FFR): A pressure-wire (Volcano PrimeWire, Abbott Aeris) is advanced distal to the stenosis; FFR ≤0.80 under adenosine-induced hyperemia indicates haemodynamically significant ischemia warranting revascularisation. The DEFER, FAME, and FAME-2 trials validated FFR-guided PCI as superior to angiography-only guidance.

• Instantaneous Wave-Free Ratio (iFR): Adenosine-free resting index (iFR ≤0.89 = significant); validated in the DEFINE-FLAIR and iFR-SWEDEHEART trials as equivalent to FFR.

• Resting Full-Cycle Ratio (RFR) and diastolic pressure ratio (dPR) are additional resting indices available on modern systems.

INTRAVASCULAR IMAGING (HIGH-RESOLUTION PLAQUE AND LUMEN ASSESSMENT):

• Intravascular Ultrasound (IVUS): 40–60 MHz rotating transducer provides cross-sectional lumen and plaque morphology; minimum lumen area (MLA) <6 mm² in LM and <4 mm² in non-LM vessels guides revascularization decisions. IVUS-guided PCI is associated with lower MACE at 1 year (ULTIMATE, IVUS-XPL trials).

• Optical Coherence Tomography (OCT): Near-infrared light; 10x higher resolution than IVUS (10–15 µm); ideal for thin-cap fibroatheroma detection, stent apposition assessment, and edge dissection identification. OCT requires contrast flushing for blood clearance.

CT CORONARY ANGIOGRAPHY (CCTA) — NON-INVASIVE ALTERNATIVE:

Dual-source or 320-detector row CT scanners (Siemens SOMATOM Force, Canon Aquilion ONE PRISM) can non-invasively characterize coronary anatomy with high sensitivity (95–99%) and specificity (64–83%). CT-FFR (HeartFlow FFRCT) provides functional stenosis assessment without catheterization. CCTA is preferred in low-to-intermediate pre-test probability patients, reducing unnecessary invasive procedures per the SCOT-HEART and PROMISE trials.

PERCUTANEOUS CORONARY INTERVENTION (PCI) — PERFORMED IN THE SAME SITTING IF INDICATED:

When diagnostic angiography reveals a significant lesion, ad-hoc PCI may be performed in the same session (staged or immediate). Modern PCI techniques include:

• Drug-Eluting Stent (DES) implantation: 3rd and 4th generation DES (Orsiro, Synergy, Ultimaster) with biodegradable polymer and ultrathin struts (60–80 µm) reduce restenosis to <5% at 1 year.

• Drug-Coated Balloon (DCB) angioplasty: For in-stent restenosis, small vessels (<2.5 mm), and bifurcation side branches.

• Rotational or Orbital Atherectomy: For heavily calcified lesions (Rotablator, Diamondback 360) prior to stent delivery.

• Intravascular Lithotripsy (IVL — Shockwave Medical): For severely calcified lesions, allowing plaque modification without vessel trauma.

• Bifurcation PCI: Provisional T-stenting, Culotte, TAP, DK-Crush techniques for LM or complex bifurcations.

PRE-PROCEDURE (Days −7 to −1):

• GAF Healthcare case manager conducts a virtual pre-consultation with an interventional cardiologist using uploaded records (ECG, echo, stress test, blood reports).

• Antiplatelet therapy bridging plan established: aspirin 75–325 mg/day continued; clopidogrel/ticagrelor management per operator preference.

• Anticoagulants (warfarin, DOACs) managed per bridging protocol — typically held 48–72 hours pre-procedure for elective cases.

• Contrast allergy pre-medication protocol initiated if applicable (methylprednisolone 32 mg at 12h and 2h pre-procedure + diphenhydramine 50 mg).

• NPO (nil per mouth) for solids 6 hours pre-procedure; clear liquids until 2 hours before.

• Radial artery patency confirmed via modified Allen's test or pulse oximetry plethysmography.

• eGFR assessed; intravenous pre-hydration with 0.9% normal saline initiated for eGFR <60 (Mehran protocol: 1 mL/kg/hr × 12h pre and 12h post).

• Patient arrives at GAF Healthcare partner hospital; dedicated international patient coordinator facilitates admission and documentation.

DAY OF PROCEDURE:

• Pre-procedure: IV cannula placed, baseline vitals recorded, surgical site (wrist/groin) prepared and draped, procedural consent obtained with interpreter support if needed.

• Sedation: Conscious sedation (IV midazolam 1–2 mg + fentanyl 25–50 mcg) or procedural anxiolysis; general anesthesia not required.

• Procedure (20–45 minutes): Radial/femoral access secured → sheath insertion → intravenous unfractionated heparin (UFH 50–70 IU/kg) administered → selective coronary engagement with guiding catheter → contrast injection in standard orthogonal projections → optional FFR/iFR/IVUS/OCT performed → if PCI indicated, balloon pre-dilation → DES implantation under IVUS/OCT guidance → post-dilation to ensure optimal stent expansion → angiographic result confirmed.

• Access site management: Radial — TR-Band applied, deflated progressively over 2–4 hours (patent haemostasis protocol). Femoral — closure device deployed; ambulation after 2–4 hours of bed rest.

POST-PROCEDURE (Day 0–1 — Hospital):

• Continuous cardiac monitoring (ECG telemetry) for 2–6 hours post-procedure.

• Serial vitals, access-site checks, and neurovascular assessment of radial/femoral limb.

• Renal function rechecked at 24 hours (contrast-induced nephropathy surveillance — peak creatinine rise typically at 48–72h).

• Antiplatelet therapy (dual antiplatelet therapy — DAPT: aspirin + P2Y12 inhibitor) prescribed if stent implanted: duration 1–6 months for DES per ARC-HBR or standard bleeding risk assessment.

• High-intensity statin therapy initiated or optimised (rosuvastatin 20–40 mg or atorvastatin 40–80 mg).

• Discharge same day (day-care) or next morning if observations are satisfactory.

DAY 2–7 (RECOVERY IN COUNTRY — HOTEL/RECOVERY ACCOMMODATION):

• Light activities permitted; no lifting >5 kg, no vigorous exercise.

• Access-site wound inspection at 48 hours; radial artery occlusion surveillance.

• Any contrast-induced nephropathy symptoms monitored; hydration maintained.

• Follow-up teleconsult with cardiologist at Day 3 to review discharge vitals and bloods.

• GAF Healthcare coordinator arranges post-discharge echo or ECG if PCI was performed.

FIT-TO-FLY CLEARANCE:

• Diagnostic angiography only (no intervention): Generally fit to fly after 48–72 hours if access site is healed and renal function is stable.

• Angiography with ad-hoc PCI: Fit to fly after 5–7 days for short-haul, 10–14 days for long-haul intercontinental flights, following cardiologist sign-off, stable renal function, and no post-PCI complications (no new ST changes, no chest pain, CK-MB/troponin trending down).

• Medical fitness-to-fly certificate issued by the treating cardiologist through GAF Healthcare.

LONG-TERM FOLLOW-UP (BACK HOME):

• DAPT compliance: First follow-up at 1 month — cardiologist review (can be virtual via GAF telemedicine).

• LDL-C target: <55 mg/dL (1.4 mmol/L) for very-high-risk CAD patients per ESC 2021 Dyslipidaemia Guidelines.

• Lifestyle modification programme: Cardiac rehabilitation, Mediterranean or DASH diet, aerobic exercise 150 min/week, smoking cessation, glycaemic control.

• Repeat functional testing (stress echo or nuclear MPI) at 6–12 months if PCI performed.