What is the role of cardiac angiography in the workup of acute coronary syndrome (ACS)?

Updated: Sep 30, 2020
  • Author: David L Coven, MD, PhD; Chief Editor: Eric H Yang, MD  more...
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Cardiac catheterization helps in defining coronary anatomy and the extent of a patient’s disease.

Patients with cardiogenic shock, intractable angina (despite medication), severe pulmonary congestion, or right ventricular (RV) infarction should immediately undergo cardiac catheterization. (Cardiogenic shock is defined as a systolic BP of less than 90 mm Hg in the presence of organ hypoperfusion.)

For high-risk patients with ACS without persistent ST elevation, angiography with glycoprotein IIb/IIIa inhibition has been recommended. The earlier that coronary angiography is performed, the lower the risk of recurrent ischaemia. [45] This also shortens the hospital stay for those patients.

Most patients benefit from angiography when they have a TIMI (Thrombolysis in Myocardial Infarction) risk score of less than 3 points (see Table 2, below).

Table 2. TIMI Risk Score for Unstable Angina and NSTEMI [46] (Open Table in a new window)


Risk Score


Age ≥65 years


At least 3 risk factors for coronary heart disease


Previous coronary stenosis ≥50%


Use of aspirin in previous 7 days



At least 2 anginal episodes in the previous 24 hours


ST-segment elevation on admission ECG


Elevated levels of serum biomarkers


Total Score


Note: Event rates significantly increased as the TIMI risk score increased in the test cohort in the TIMI IIB study. Rates were 4.7% for a score of 0/1, 8.3% for 2, 13.2% for 3, 19.9% for 4, 26.2% for 5, and 40.9% for 6/7 (P< .001, χ2 test for the trend). The pattern of increasing event rates with increasing TIMI risk score was confirmed in all 3 validation groups (P< .001).

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