ABC | Volume 112, Nº5, May 2019

Original Article Luciano et al Analysis of coronariographies in Southern Brazil Arq Bras Cardiol. 2019; 112(5):526-531 coronary angiography in New York, 9 and in a large Canadian cohort of patients suspected of having a stable CAD, were evaluated. 10 The results in the literature are discordant regarding the validation of the guideline, generating concern about its reliability to guide decision-making. 10 The objective of this study is to analyze the appropriation of coronary angiographies performed in two hospitals in the southern region of Brazil in accordance with the 2012 guidelines. Methods This is an observational, cross-sectional, multicenter study. The two centers together performmore than 1,700 procedures per year; one of them is a tertiary hospital with multiple specialties (Hospital A) and the other a tertiary cardiology hospital (Hospital B). All the elective or emergency coronary angiograms were included in the period from May to October 2016. Catheterizations performed in cases of acute myocardial infarction with ST segment elevation were excluded. The information was entered into a database at the time of the procedure. The work was approved by the Research Ethics Committees of the institutions involved. All indications were classified as appropriate, occasionally appropriate, or rarely appropriate, according to current terminology, 11 and following the 2012 guidelines for appropriate use of diagnostic cardiac catheterization. In this guideline, indications are divided into three broad groups: 1. Evaluation of CAD; 2. Evaluation due to conditions other than CAD (valvar, pericardial or cardiomyopathy diseases); 3. Right heart catheterization. The guideline covers 102 possible indications, which were classified by a score that combines evidence-based medicine and practical experience of the members of a technical panel. Each indication received an average score of 1 to 9, being classified as appropriate when between 7 and 9, occasionally appropriate when between 4 and 6, and rarely appropriate when between 1 and 3. 6 The analysis also included age, sex, clinical status, coronary angiographic findings regarding the presence of obstructive disease, and the treatment proposal. The clinical picture was simply characterized as an acute coronary syndrome (ACS) or as a stable condition, which included all patients who did not fit the first group. ACS was characterized by presenting with typical chest pain at rest or in progress, associated or not with the electrocardiographic alteration suggestive of ischemia (ST segment depression and/ or T wave alteration), and may or may not be associated with changes in myocardial necrosis markers. 12 In order to check if the recommendation of the guideline adequately predicts the angiographic result and therapeutic perspective, the coronary angiography result was classified according to the extent of the severe CAD, and the treatment proposal for each case was documented. A reduction of greater than or equal to 50% in the diameter of the left coronary artery trunk (LCT), and greater than or equal to 70% for the other vessels, was considered severe, either by visual angiographic evaluation or by quantitative angiography, with the projection in which the lesion was more severe being chosen. 11,13 Patients with severe LCT lesions were classified regardless of the presence of other severe lesions. The treatment proposal was defined by the hemodynamicist in charge, after coronary angiography, and may be clinical treatment, coronary angioplasty or myocardial revascularization surgery, according to available clinical data and the anatomical result found in the examination. Data analysis was performed in order to also allow the comparison between two services with different profiles, with Hospital A being a general hospital and Hospital B a reference center for high complexity in cardiology in the state, with a large flow of coronary patients in its emergency service. The two services are provided exclusively by the Unified Health System (SUS). Statistical Analysis For data analysis, the IBM SPSS Statistics 23 software (IBM Corp. Released 2015, IBM SPSS Statistics for Windows, Version 23.0, Armonk, NY: IBM Corp.) was used. The results were expressed in numbers and (absolute and relative) proportion, for categorical variables, and inmeasures of central trend (mean) and dispersion (standard deviation) for continuous variables. The chi-square test was used to study possible associations between categorical variables. For the comparison between continuous variables, the unpaired Student t test was used. The Kolmogorov-Smirnov test was applied to evaluate the sample normality assumption. The level of statistical significance adopted was 5%, considering a 95% confidence interval. Results Of the 737 coronary angiograms analyzed, 76.8% were performed at Hospital B, 63.9% in male patients. The mean age was 61.6 years. The indication for coronary angiography was due to ACS in 57.1%, and CAD investigation in 42.9% of the cases. Regarding appropriation, 80.6% of the coronary angiograms were classified as appropriate, 15.1% occasionally appropriate, and 4.3% rarely appropriate. We observed that 41.2% of coronary angiograms did not show severe CAD, 27.4% severe single-vessel CAD, 17.2% two-vessel CAD, 11.3% three-vessel CAD, and 2.8% severe LCT lesion. The proposed treatment was clinical for 62.7% of the patients, percutaneous coronary intervention for 24.6%, and myocardial revascularization surgery for 12.7% of the cases. There was no statistically significant difference in the prevalence of male and female patients between the two institutions (Table 1). The mean age was 59.1 years in Hospital A, and 62.3 years in Hospital B (p < 0.05). All patients with ACS have appropriate indication for coronary angiography. In this group of patients there was no statistically significant difference regarding the distribution by gender, coronary angiography result and treatment (Table 2). Among the stable patients, there was a lower proportion of patients with appropriate indications in Hospital A compared to Hospital B and a higher proportion of occasionally appropriate ones. Among the stable patients, no difference was observed regarding the distribution by gender, outcome and treatment. There was a higher incidence of indication 527